Basic Information
| Provider Information | |||||||||
| NPI: | 1376512616 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIRTH | ||||||||
| FirstName: | LYNNE | ||||||||
| MiddleName: | SUSAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2920 HIGHWOODS BLVD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276040010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774984490 | ||||||||
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| Practice Location | |||||||||
| Address1: | 204 MEDSPRING DR | ||||||||
| Address2: | |||||||||
| City: | CLAYTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275209293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192356505 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2006 | ||||||||
| LastUpdateDate: | 04/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | 33770 | NC | Y | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
ID Information
| ID | Type | State | Issuer | Description | 88599 | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER | 7873164 | 01 | NC | AETNA | OTHER | 8988599 | 05 | NC | MEDICAID |