MEDICARE: WAYNE HEALTH FAMILY MEDICINE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1386075612
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAYNE HEALTH FAMILY MEDICINE LLC

Provider Business Mailing Address
First Line	:	PO BOX 1717
Second Line	:
City	:	GOLDSBORO
State	:	NC
Zip	:	27533-1717
Country	:	US
Telephone Number	:	919-587-4081
Fax Number	:	919-587-0775

Provider Business Practice Location Address
First Line	:	210 N HERMAN ST
Second Line	:
City	:	GOLDSBORO
State	:	NC
Zip	:	27530-3810
Country	:	US
Telephone Number	:	919-587-4081
Fax Number	:	919-587-0775

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. CLYDE LOUIS THOMAS II
Credential	:
Telephone Number	:	919-587-4081

Provider Enumeration Date	:	12/12/2013
Last Update Date	:	08/30/2016

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