Basic Information
| Provider Information | |||||||||
| NPI: | 1043251960 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAKE EMERGENCY PHYSICIANS PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 890053 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282890053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432373378 | ||||||||
| FaxNumber: | 8432375073 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 KILDAIRE FARM RD | ||||||||
| Address2: | |||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432373378 | ||||||||
| FaxNumber: | 8432375073 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 05/24/2018 | ||||||||
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| AuthorizedOfficialLastName: | RALEY | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9198593373 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0295F | 01 | NC | BCBS STATE | OTHER | QPB978 | 05 | SC | MEDICAID | 0298N | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER | 890298N | 05 | NC | MEDICAID | CD5224 | 01 | NC | RAILROAD MEDICARE | OTHER |