Advance Family and Sports Medicine Center, PLLC
Organization Active NPI Family Medicine Physician · Advance, NC
NPI 1376854083 · NPPES record last updated Nov 5, 2010
Key facts
- NPI
- 1376854083
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Family Medicine Physician 207Q00000X
- Legal business name
- ADVANCE FAMILY AND SPORTS MEDICINE CENTER, PLLC
- Practice address
- 169 Yadkin Valley Rd
Suite 101
Advance, NC 27006-8786 - Phone
- (336) 940-2659
- NPI assigned
- Jun 28, 2010
- Organization subpart
- No
Authorized official
- Name
- Dr. Walter Ezeigbo, MD
- Title
- Owner/Ceo
- Phone
- (336) 940-2659
Practitioners 2
-
Yolanda McClam Nicholson, FNP-C
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in NC
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20101011000997 | NC | Part B Supplier - Clinic/Group Practice | 9537351440 |
Receives reassigned benefits from 1 practitioner Practice locations: Winston Salem, NC |
National Provider Directory
Locations
169 Yadkin Valley Rd
Ste 101
Advance, NC 27006
Phone (336) 940-2659
1000 Southpark Blvd
Ste A
Winston Salem, NC 27127
Phone (336) 788-4545
Interoperability endpoints
- https://api.platform.athenahealth.com/8874/brand/1/csg/1/fhir/r4
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | Yes | ||
| Sports Medicine (Family Medicine) Physician |
207QS0010X |
Addresses
Primary practice location
169 Yadkin Valley Rd
Suite 101
Advance, NC 27006-8786
Mailing address
169 Yadkin Valley Rd
Suite 101
Advance, NC 27006-8786
Phone (336) 940-2659
Other providers in Advance, NC
- Adam T. Dorsett, DDS, and Jason T. Moore, DDS, PA
- Advance Pediatrics, PC
- Advance Rehabilitation and Nursing
- Devan Allred
- Stefanie Marie Alvis
- Amy Li DMD
All providers in Advance, NC · Family Medicine Physician in North Carolina
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 5, 2010. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.