Basic Information
| Provider Information | |||||||||
| NPI: | 1639454499 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WAKE FOREST UNIVERSITY HEALTH SCIENCES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WFUHS - LEXMEDICAL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | WAKE FOREST UNIVERSITY HEALTH SCIENCES | ||||||||
| Address2: | PO BOX 890355 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282890355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162255 | ||||||||
| FaxNumber: | 3367163202 | ||||||||
| Practice Location | |||||||||
| Address1: | 1303 GREENSBORO STREET EXT | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272951924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162255 | ||||||||
| FaxNumber: | 3367163202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2011 | ||||||||
| LastUpdateDate: | 02/08/2012 | ||||||||
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| AuthorizedOfficialLastName: | SIBERT | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & COO | ||||||||
| AuthorizedOfficialTelephone: | 3367162255 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WAKE FOREST UNIVERSITY HEALTH SCIENCES | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.