NPIMap

Individual provider Active NPI

John Michael Provenza, MD

  • Gastroenterology Physician
  • Winston Salem, NC
National Provider Identifier
1508399346
Registry record updated Jun 12, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Gastroenterology PhysicianTaxonomy code 207RG0100X
License
2023-01626 Issued in NC
Practice address
Medical Center Boulevard
Winston Salem, NC 27157-1900
Phone
(336) 713-7311
NPI assigned
Apr 8, 2017
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jun 12, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Gastroenterology Physician 207RG0100X 2023-01626 NC Primary
Student in an Organized Health Care Education/Training Program 390200000X

Addresses

Primary practice location

Medical Center Boulevard
Winston Salem, NC 27157-1900

Mailing address

Medical Center Blvd
Winston Salem, NC 27157-0001
Phone (336) 713-7777

Other practice location 1

625 19th St S
Birmingham, AL 35233-1900
Phone (205) 934-9666

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NC
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20230626000116 NC Practitioner - Gastroenterology 8224315049 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Gastroenterology
Education
Louisiana State University School of Medicine in Shreveport, 2013
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Wake Forest University Health SciencesGroup PAC ID 4486564952, 2,633 clinicians

Practice addresses (Care Compare)

Medical Ctr Blvd
Winston Salem, NC 27157-0001
Phone (336) 716-2734

Hospital & facility affiliations

  • North Carolina Baptist Hospital Hospital, Winston-Salem, NC, CCN 340047

Merit-based Incentive Payment System (MIPS)

Final score
99.15 of 100Reported as group
Promoting interoperability
99
Improvement activities
40

Procedures performed for Medicare patients

ProcedureNumber of procedures
Colonoscopy47
Upper gastrointestinal (GI) endoscopy for acid reflux47

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
2023-01626NCMDGastroenterology Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Wake Forest University Health Sciences Gastroenterology CurrentSince Jun 12, 2023 Accepting new patients
North Carolina Baptist Hospital Past Accepting new patients

Locations

500 Shepherd St
Ste 300
Winston Salem, NC 27103
Phone (336) 713-7777

Medical Ctr Blvd
Winston Salem, NC 27157
Phone (336) 713-2697

101 Charlois Blvd
Ste 102
Winston Salem, NC 27103
Phone (336) 713-0341

Interoperability endpoints

  • Direct secure messaging: jprovenza2754853@carolinashealthcaresystem.direct-ci.com

Organizations & group practices 2

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 5

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1491609600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1686528000000",
    "number": "1508399346",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "MEDICAL CENTER BLVD",
            "city": "WINSTON SALEM",
            "state": "NC",
            "postal_code": "271570001",
            "telephone_number": "336-713-7777",
            "fax_number": "336-716-1119"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "MEDICAL CENTER BOULEVARD",
            "city": "WINSTON SALEM",
            "state": "NC",
            "postal_code": "271571900",
            "telephone_number": "336-713-7311"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "625 19th St S",
            "address_purpose": "LOCATION",
            "city": "Birmingham",
            "state": "AL",
            "postal_code": "352331900",
            "country_code": "US",
            "telephone_number": "205-934-9666",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "PROVENZA",
        "first_name": "JOHN",
        "middle_name": "MICHAEL",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2017-04-08",
        "last_updated": "2023-06-12",
        "certification_date": "2023-06-12",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207RG0100X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Gastroenterology",
            "state": "NC",
            "license": "2023-01626",
            "primary": true
        },
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Winston Salem, NC

Sources for this page

Verify at the official NPI Registry.