1861564924 NPI number — WAKELON INTERNAL MEDICINE PLLC

Table of content: (NPI 1861564924)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861564924 NPI number — WAKELON INTERNAL MEDICINE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAKELON INTERNAL MEDICINE PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861564924
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/04/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 HOSPITAL ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ZEBULON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27597
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-269-0390
Provider Business Mailing Address Fax Number:
919-269-6868

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 HOSPITAL ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ZEBULON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27597
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-269-0390
Provider Business Practice Location Address Fax Number:
919-269-6868
Provider Enumeration Date:
11/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WEST
Authorized Official First Name:
SHELLY
Authorized Official Middle Name:
LORRAINE
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
919-269-0390

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  200001025 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 127GV . This is a "BC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 2022572 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 89127GV , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2077334 . This is a "FIRST HEALTH" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: P00255758 . This is a "RR MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7632748 . This is a "AETNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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