Provider Demographics
NPI:1053692079
Name:WEST FORSYTH PAIN MANAGEMENT
Entity type:Organization
Organization Name:WEST FORSYTH PAIN MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:ZIMMERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:336-740-9444
Mailing Address - Street 1:2554 LEWISVILLE CLEMMONS RD
Mailing Address - Street 2:SUITE 211
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-8110
Mailing Address - Country:US
Mailing Address - Phone:336-740-9444
Mailing Address - Fax:336-740-9445
Practice Address - Street 1:2554 LEWISVILLE CLEMMONS RD
Practice Address - Street 2:SUITE 211
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8110
Practice Address - Country:US
Practice Address - Phone:336-740-9444
Practice Address - Fax:336-740-9445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-03
Last Update Date:2011-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101887363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
S21055Medicare UPIN