Basic Information
| Provider Information | |||||||||
| NPI: | 1265923205 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WAKE EMERGENCY PHYSICIANS PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | RELYMD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 TOWNE VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275138910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198593373 | ||||||||
| FaxNumber: | 9193364363 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 TOWNE VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275138910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198593373 | ||||||||
| FaxNumber: | 9193364363 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2018 | ||||||||
| LastUpdateDate: | 05/25/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | ALLEN | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9193484481 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WAKE EMERGENCY PHYSICIANS PA | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | NC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 208D00000X | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.