Provider Demographics
NPI:1447370101
Name:OLD TOWN FAMILY MEDICINE, P A
Entity type:Organization
Organization Name:OLD TOWN FAMILY MEDICINE, P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:HERBER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-922-1363
Mailing Address - Street 1:3690 REYNOLDA RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-2230
Mailing Address - Country:US
Mailing Address - Phone:336-922-1363
Mailing Address - Fax:
Practice Address - Street 1:3690 REYNOLDA RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-2230
Practice Address - Country:US
Practice Address - Phone:336-922-1363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC39614261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8941873Medicaid
NC2346254Medicare ID - Type Unspecified
NC8941873Medicaid