Basic Information
| Provider Information | |||||||||
| NPI: | 1750319729 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | REX HOSPITAL INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | REX FAMILY PRACTICE OF WAKEFIELD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11200 GOVERNOR MANLY WAY | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276146830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195707700 | ||||||||
| FaxNumber: | 9195707701 | ||||||||
| Practice Location | |||||||||
| Address1: | 11200 GOVERNOR MANLY WAY | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276146830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195707700 | ||||||||
| FaxNumber: | 9195707701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 04/28/2009 | ||||||||
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| AuthorizedOfficialLastName: | SPONG | ||||||||
| AuthorizedOfficialFirstName: | BERNADETTE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9197843245 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | 89014XV | 05 | NC | MEDICAID | 7607516 | 01 | AETNA | OTHER | 014XV | 01 | NC | BCBS | OTHER |