Basic Information
| Provider Information | |||||||||
| NPI: | 1972579837 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WAKEMED | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WAKEMED RALEIGH CAMPUS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3000 NEW BERN AVE | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276101295 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193508000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3000 NEW BERN AVE | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276101295 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193508000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 06/12/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CARRICO | ||||||||
| AuthorizedOfficialFirstName: | RICK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VP, FINANCE & CFO | ||||||||
| AuthorizedOfficialTelephone: | 9193508000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WAKEMED | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | N | Hospital Units | Medicare Defined Swing Bed Unit | 282N00000X | H0199 | NC | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 011 | 01 | NC | CHAMPUS | OTHER | 3400069A | 05 | NC | MEDICAID | 00356 | 01 | NC | BLUE CROSS | OTHER | 00361 | 01 | NC | BLUE CROSS | OTHER | 3400069 | 05 | NC | MEDICAID | 003 | 01 | NC | CHAMPUS | OTHER | 3400069F | 05 | NY | MEDICAID | 009 | 01 | NC | CHAMPUS | OTHER | 3400069E | 05 | NC | MEDICAID | 002C9 | 01 | NC | BCBS PROVIDER NUMBER | OTHER |