Basic Information
| Provider Information | |||||||||
| NPI: | 1225268238 | ||||||||
| 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: | 9198593373 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2138 HIGHWAY 42 WEST | ||||||||
| Address2: | |||||||||
| City: | CLAYTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432373378 | ||||||||
| FaxNumber: | 8432375073 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2009 | ||||||||
| 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 | BSNC | OTHER | 5912279 | 05 | NC | MEDICAID | CD5224 | 01 | NC | RAILROAD MEDICARE | OTHER |