Basic Information
| Provider Information | |||||||||
| NPI: | 1790935815 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAKE FOREST UNIVERSITY HEALTH SCIENCES | ||||||||
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| OtherOrganizationName: | WFU HEALTH SCIENCES-MAPLEWOOD OB-GYN | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2830 MAPLEWOOD AVE | ||||||||
| Address2: | SUITE C | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271034114 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2830 MAPLEWOOD AVE | ||||||||
| Address2: | SUITE C | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271034114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162255 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2008 | ||||||||
| LastUpdateDate: | 09/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | APPLEGATE | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM PRES, WFU HEALTH SCIENCES | ||||||||
| AuthorizedOfficialTelephone: | 3367164424 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WAKE FOREST UNIVERSITY HEALTH SCIENCES | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.