Basic Information
| Provider Information | |||||||||
| NPI: | 1659987170 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAKEMED | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602368 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602368 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | WAKEMED RALEIGH REFERENCE | ||||||||
| Address2: | 3000 NEW BERN AVENUE | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276101295 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193508000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2020 | ||||||||
| LastUpdateDate: | 09/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | FLYNN | ||||||||
| AuthorizedOfficialFirstName: | TERENCE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF REIMBURSEMENT | ||||||||
| AuthorizedOfficialTelephone: | 9193500534 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WAKEMED HEALTH & HOSPITALS | ||||||||
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| NPICertificationDate: | 09/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.