1568696748 NPI number — WAKE SPINE & PAIN SPECIALISTS PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568696748 NPI number — WAKE SPINE & PAIN SPECIALISTS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAKE SPINE & PAIN SPECIALISTS PC
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:
1568696748
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3801 WAKE FOREST RD STE 210
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27609-6864
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-787-7246
Provider Business Mailing Address Fax Number:
919-787-7247

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 KILDAIRE PARK DRIVE
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
CARY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27518
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-787-7246
Provider Business Practice Location Address Fax Number:
919-787-7247
Provider Enumeration Date:
05/04/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MAUCERI
Authorized Official First Name:
BERNADETTE
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
919-787-7246

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1493M . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: DP4614 . This is a "RAILROAD MEDICARE GROUP PTAN" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5910579 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2022628A . This is a "MEDICARE PTAN" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: P00759335 . This is a "RAILROAD MEDICARE GROUP MEMBER PTAN" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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