1700490232 NPI number — WAKE FOREST BAPTIST IMAGING, LLC

Table of content: (NPI 1700490232)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700490232 NPI number — WAKE FOREST BAPTIST IMAGING, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAKE FOREST BAPTIST IMAGING, LLC
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:
1700490232
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 CRESCENT CENTRE DR STE 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRANKLIN
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37067-7270
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-261-2306
Provider Business Mailing Address Fax Number:
855-588-3545

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
861 OLD WINSTON RD STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KERNERSVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27284-7141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-765-5722
Provider Business Practice Location Address Fax Number:
336-765-5723
Provider Enumeration Date:
09/02/2020

Additional Information

Authorized Official

Authorized Official Last Name:
STOUT
Authorized Official First Name:
AMY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
615-261-2306

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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