1982681904 NPI number — MT. AIRY DIALYSIS CENTER OF WAKE FOREST UNIVERSITY

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 1982681904 NPI number — MT. AIRY DIALYSIS CENTER OF WAKE FOREST UNIVERSITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MT. AIRY DIALYSIS CENTER OF WAKE FOREST UNIVERSITY
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:
1982681904
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7710
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TIFTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31793-7710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-387-3527
Provider Business Mailing Address Fax Number:
229-386-2149

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1280 NEWSOME ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MT AIRY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27030-5442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-789-4090
Provider Business Practice Location Address Fax Number:
336-789-9629
Provider Enumeration Date:
12/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HALES
Authorized Official First Name:
TERRY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
ASSISTANT TREASURER
Authorized Official Telephone Number:
336-716-3003

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , 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: 3412551 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0054Q . This is a "BCBS-NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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