Basic Information
| Provider Information | |||||||||
| NPI: | 1235192725 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAPE FEAR CARDIOVASCULAR & THORACIC SURGERY PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 61056 | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277151056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195446318 | ||||||||
| FaxNumber: | 9195446336 | ||||||||
| Practice Location | |||||||||
| Address1: | 2153 VALLEYGATE DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283043667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106720350 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WELSHER | ||||||||
| AuthorizedOfficialFirstName: | WAYNE | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9106720350 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 690189Q | 05 | NC | MEDICAID |