1114911823 NPI number — SAMUEL M WESONGA MD

Table of content: SAMUEL M WESONGA MD (NPI 1114911823)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114911823 NPI number — SAMUEL M WESONGA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WESONGA
Provider First Name:
SAMUEL
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WESONGA
Provider Other First Name:
SAM
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1114911823
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2920 HIGHWOODS BLVD
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:
27604-0010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-498-4490
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8001 T W ALEXANDER DR STE 216
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27617-4884
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-350-0953
Provider Business Practice Location Address Fax Number:
193-509-8189
Provider Enumeration Date:
09/08/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  93-00369 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 9300369 , 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: 80084731 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 8986588 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 59381 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 86588 . This is a "BCBSNC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5497949 . This is a "CIGNA HEALTHCARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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