Provider Demographics
NPI:1871797688
Name:WAKE FOREST UNIVERSITY BAPTIST MEDICAL CENTER COMMUNITY PHYSICIANS
Entity type:Organization
Organization Name:WAKE FOREST UNIVERSITY BAPTIST MEDICAL CENTER COMMUNITY PHYSICIANS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LEWIS
Authorized Official - Middle Name:S
Authorized Official - Last Name:THORP
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:336-721-3900
Mailing Address - Street 1:5175 OLD CLEMMONS SCHOOL ROAD
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-9394
Mailing Address - Country:US
Mailing Address - Phone:336-778-0200
Mailing Address - Fax:336-778-0202
Practice Address - Street 1:5175 OLD CLEMMONS SCHOOL ROAD
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012
Practice Address - Country:US
Practice Address - Phone:336-778-0200
Practice Address - Fax:336-778-0202
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAKE FOREST UNIVERSITY BAPTIST MEDICAL CENTER COMMUNITY PHYSICIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-14
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2317728WOtherMEDICARE GROUP NUMBER