Basic Information
| Provider Information | |||||||||
| NPI: | 1821694381 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RALEIGH RADIOLOGY WAKEMED IMAGING, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5220 GREENS DAIRY RD | ||||||||
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| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276164612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197811437 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11640 NORTHPARK DR STE 110 | ||||||||
| Address2: | |||||||||
| City: | WAKE FOREST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275875741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197811437 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2020 | ||||||||
| LastUpdateDate: | 09/13/2021 | ||||||||
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| AuthorizedOfficialLastName: | MATHAN | ||||||||
| AuthorizedOfficialFirstName: | SATISH | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 9197811437 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 08/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.