Basic Information
| Provider Information | |||||||||
| NPI: | 1093752693 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEDEGAERTNER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ROSE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 97 CORNERSTONE DR | ||||||||
| Address2: | |||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275198403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194600993 | ||||||||
| FaxNumber: | 9194823952 | ||||||||
| Practice Location | |||||||||
| Address1: | 97 CORNERSTONE DR | ||||||||
| Address2: | |||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275198403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194600993 | ||||||||
| FaxNumber: | 9194813952 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 08/07/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 36851 | NC | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 8986293 | 05 | NC | MEDICAID | 86293 | 01 | NC | BCBS | OTHER |