Healthcare Provider Details

I. General information

NPI: 1871658443
Provider Name (Legal Business Name): WAVERLY HEMATOLOGY ONCOLOGY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 10/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 ASHVILLE AVE SUITE 310
CARY NC
27518-8682
US

IV. Provider business mailing address

300 ASHVILLE AVE SUITE 310
CARY NC
27518-8682
US

V. Phone/Fax

Practice location:
  • Phone: 919-233-8585
  • Fax: 919-233-8566
Mailing address:
  • Phone: 919-233-8585
  • Fax: 919-233-8566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number39812
License Number StateNC

VIII. Authorized Official

Name: MARK GRAHAM II
Title or Position: DIRECTOR
Credential: MD
Phone: 919-233-8585