1861564924 NPI number — WAKELON INTERNAL MEDICINE PLLC

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 1861564924 NPI number — WAKELON INTERNAL MEDICINE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAKELON INTERNAL MEDICINE PLLC
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:
1861564924
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/04/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 HOSPITAL ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ZEBULON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27597
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-269-0390
Provider Business Mailing Address Fax Number:
919-269-6868

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 HOSPITAL ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ZEBULON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27597
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-269-0390
Provider Business Practice Location Address Fax Number:
919-269-6868
Provider Enumeration Date:
11/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WEST
Authorized Official First Name:
SHELLY
Authorized Official Middle Name:
LORRAINE
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
919-269-0390

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  200001025 , 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: 127GV . This is a "BC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 2022572 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 89127GV , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2077334 . This is a "FIRST HEALTH" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: P00255758 . This is a "RR MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7632748 . This is a "AETNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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