Basic Information
| Provider Information | |||||||||
| NPI: | 1699760926 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAKE INTERNAL MEDICINE CONSULTANTS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 BLUE RIDGE RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276128036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197817500 | ||||||||
| FaxNumber: | 9198819586 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 BLUE RIDGE RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276128036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197817500 | ||||||||
| FaxNumber: | 9198819586 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2005 | ||||||||
| LastUpdateDate: | 08/25/2011 | ||||||||
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| AuthorizedOfficialLastName: | MERO | ||||||||
| AuthorizedOfficialFirstName: | GAIL | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 9197817500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RP1001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207UN0901X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8902915 | 05 | NC | MEDICAID |