1972596211 NPI number — WAKE FOREST UNIVERSITY BAPTIST MEDICAL CENTER COMMUNITY PHYSICIANS

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 1972596211 NPI number — WAKE FOREST UNIVERSITY BAPTIST MEDICAL CENTER COMMUNITY PHYSICIANS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAKE FOREST UNIVERSITY BAPTIST MEDICAL CENTER COMMUNITY PHYSICIANS
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:
6
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:
1972596211
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2468
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KING
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27021-2468
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-983-3878
Provider Business Mailing Address Fax Number:
336-983-3016

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
167 MOORE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KING
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27021-8770
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-983-3878
Provider Business Practice Location Address Fax Number:
336-983-3016
Provider Enumeration Date:
08/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
THORP
Authorized Official First Name:
LEWIS
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESIDENT CEO
Authorized Official Telephone Number:
336-721-3900

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , 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: 7690216C , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2317728P . This is a "MEDICARE GROUP NUMBER" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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