Basic Information
| Provider Information | |||||||||
| NPI: | 1376841874 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNC PHYSICIANS NETWORK, LLC | ||||||||
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| OtherOrganizationName: | REX FAMILY PRACTICE OF WAKEFIELD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 PERIMETER PARK DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MORRISVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275608442 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11200 GOVERNOR MANLY WAY STE 205 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276147367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195707700 | ||||||||
| FaxNumber: | 9195707701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2011 | ||||||||
| LastUpdateDate: | 08/14/2019 | ||||||||
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| AuthorizedOfficialLastName: | FISCUS | ||||||||
| AuthorizedOfficialFirstName: | LYNNE | ||||||||
| AuthorizedOfficialMiddleName: | CHRISTINE | ||||||||
| AuthorizedOfficialTitleorPosition: | CMO | ||||||||
| AuthorizedOfficialTelephone: | 9842154111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1376841874 | 05 | NC | MEDICAID |