Basic Information
| Provider Information | |||||||||
| NPI: | 1396978169 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAYNE HEALTH PHYSICIANS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 250 | ||||||||
| Address2: | |||||||||
| City: | BEAVER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150090250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006340201 | ||||||||
| FaxNumber: | 8667270896 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 WAYNE MEMORIAL DR | ||||||||
| Address2: | SUITE J | ||||||||
| City: | GOLDSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275341789 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195874081 | ||||||||
| FaxNumber: | 9195870775 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2009 | ||||||||
| LastUpdateDate: | 09/14/2016 | ||||||||
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| AuthorizedOfficialLastName: | THOMAS | ||||||||
| AuthorizedOfficialFirstName: | CLYDE | ||||||||
| AuthorizedOfficialMiddleName: | LOUIS | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9195874081 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WAYNE HEALTH CORPORATION | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 5913954 | 05 | NC | MEDICAID |