Basic Information
| Provider Information | |||||||||
| NPI: | 1598071524 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WAKEMED FACULTY PRACTICE PLAN | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WAKEMED FACULTY PHYSICIANS - RALEIGH CARDIOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3000 NEW BERN AVE | ||||||||
| Address2: | SUITE 1200 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276101245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192316132 | ||||||||
| FaxNumber: | 9192316276 | ||||||||
| Practice Location | |||||||||
| Address1: | 3000 NEW BERN AVE | ||||||||
| Address2: | SUITE 1200 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276101245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192316132 | ||||||||
| FaxNumber: | 9192316276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2010 | ||||||||
| LastUpdateDate: | 08/31/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WEAVER | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | TUCKER | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9193508228 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WAKEMED FACULTY PRACTICE PLAN | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.