1760523260 NPI number — WESTERN WAKE INTERNAL MEDICINE

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 1760523260 NPI number — WESTERN WAKE INTERNAL MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WESTERN WAKE INTERNAL MEDICINE
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:
1760523260
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2025 GIOVANNI CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARY
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27518-7106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-319-6610
Provider Business Mailing Address Fax Number:
919-319-6365

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
907 KILDAIRE FARM RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27511-3922
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-319-6610
Provider Business Practice Location Address Fax Number:
919-319-6365
Provider Enumeration Date:
02/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
POLAVARAM
Authorized Official First Name:
VIJAYA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
919-870-0197

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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