Basic Information
| Provider Information | |||||||||
| NPI: | 1558630699 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAYNE HEALTH MEDICAL CLINIC, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1717 | ||||||||
| Address2: | |||||||||
| City: | GOLDSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275331717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195874081 | ||||||||
| FaxNumber: | 9195870775 | ||||||||
| Practice Location | |||||||||
| Address1: | 208 COX BLVD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | GOLDSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275349414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195874081 | ||||||||
| FaxNumber: | 9195870775 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2011 | ||||||||
| LastUpdateDate: | 12/10/2015 | ||||||||
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| AuthorizedOfficialLastName: | THOMAS | ||||||||
| AuthorizedOfficialFirstName: | CLYDE | ||||||||
| AuthorizedOfficialMiddleName: | LOUIS | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9195874081 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WAYNE HEALTH PHYSICIANS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
No ID Information.