Healthcare Provider Details

I. General information

NPI: 1093752693
Provider Name (Legal Business Name): MARY ROSE WEDEGAERTNER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 08/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

97 CORNERSTONE DR
CARY NC
27519-8403
US

IV. Provider business mailing address

97 CORNERSTONE DR
CARY NC
27519-8403
US

V. Phone/Fax

Practice location:
  • Phone: 919-460-0993
  • Fax: 919-481-3952
Mailing address:
  • Phone: 919-460-0993
  • Fax: 919-482-3952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number36851
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier8986293
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer
# 2
Identifier86293
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerBCBS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: