Basic Information
| Provider Information | |||||||||
| NPI: | 1982661088 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAKE | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 877 JEFFERSON AVE | ||||||||
| Address2: | ATTN: PROVIDER ENROLLMENT | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381032807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015457302 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6555 QUINCE RD | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381198202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015155704 | ||||||||
| FaxNumber: | 9015155729 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2006 | ||||||||
| LastUpdateDate: | 03/03/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 17572 | TN | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | P01245913 | 01 | TN | RAILROAD MEDICARE | OTHER | 117837001 | 05 | AR | MEDICAID | Q002427 | 05 | TN | MEDICAID | 00010307 | 05 | MS | MEDICAID | 4355718 | 01 | TN | BCBS | OTHER |