NPIMap

Individual provider Active NPI

Theodore Prins Kistemaker, PA-C

  • Physician Assistant
  • Winston Salem, NC
National Provider Identifier
1770523557
Registry record updated Apr 28, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
103628 Issued in NC
Practice address
3333 Brookview Hills Blvd
Ste 207
Winston Salem, NC 27103-5661
Phone
(336) 765-5250
Fax
(336) 659-0953
NPI assigned
Jun 8, 2006
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Apr 28, 2014

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X 103628 NC Primary

Addresses

Primary practice location

3333 Brookview Hills Blvd
Ste 207
Winston Salem, NC 27103-5661

Mailing address

1701 Westchester Dr
Ste 850
High Point, NC 27262-7008
Phone (336) 802-2400

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
I20100212000632 NC Practitioner - Physician Assistant 8729120647 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2002
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Wake Forest University Health SciencesGroup PAC ID 4486564952, 2,633 clinicians

Practice addresses (Care Compare)

2000 W 1St St
Winston Salem, NC 27104-4225

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

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Cornerstone Health Care, LLC CurrentSince Apr 28, 2014 Accepting new patients
Wake Forest University Health Sciences CurrentSince Aug 8, 2016 Accepting new patients
Wake Forest Health Network, LLC CurrentSince Apr 28, 2014 Accepting new patients
Cornerstone Health Care PA Past Accepting new patients
Wake Forest Health Network LLC Past Accepting new patients

Locations

1701 Westchester Dr
Ste 850
High Point, NC 27262
Phone (336) 802-2400

905 Phillips Ave
High Point, NC 27262
Phone (336) 802-2040

650 Highland Ave
Ste 120
Winston Salem, NC 27101
Phone (336) 713-6111

1920 W 1st St
Winston Salem, NC 27104
Phone (336) 716-4479

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

3333 Brookview Hills Blvd
Ste 207
Winston Salem, NC 27103
Phone (336) 765-5250

1930 N Peace Haven Rd
Winston Salem, NC 27106
Phone (336) 760-5400

Interoperability endpoints

  • Direct secure messaging: tkistemaker2755364@carolinashealthcaresystem.direct-ci.com

Organizations & group practices 6

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": "1149724800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1398643200000",
    "number": "1770523557",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1701 WESTCHESTER DR",
            "address_2": "STE 850",
            "city": "HIGH POINT",
            "state": "NC",
            "postal_code": "272627008",
            "telephone_number": "336-802-2400",
            "fax_number": "336-802-2534"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3333 BROOKVIEW HILLS BLVD",
            "address_2": "STE 207",
            "city": "WINSTON SALEM",
            "state": "NC",
            "postal_code": "271035661",
            "telephone_number": "336-765-5250",
            "fax_number": "336-659-0953"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "KISTEMAKER",
        "first_name": "THEODORE",
        "middle_name": "PRINS",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-06-08",
        "last_updated": "2014-04-28",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NC",
            "license": "103628",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Winston Salem, NC

Sources for this page

Verify at the official NPI Registry.