Basic Information
| Provider Information | |||||||||
| NPI: | 1245757665 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAKE FOREST UNIVERSITY HEALTH SCIENCES | ||||||||
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| Mailing Information | |||||||||
| Address1: | MEDICAL CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271570001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162255 | ||||||||
| FaxNumber: | 3367163202 | ||||||||
| Practice Location | |||||||||
| Address1: | 557 BROOKDALE DR | ||||||||
| Address2: | |||||||||
| City: | STATESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286774107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162255 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2017 | ||||||||
| LastUpdateDate: | 08/25/2017 | ||||||||
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| AuthorizedOfficialLastName: | HIGH | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | PAUL | ||||||||
| AuthorizedOfficialTitleorPosition: | EVP HEALTH SYSTEM AFFAIRS | ||||||||
| AuthorizedOfficialTelephone: | 3367164724 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.