Healthcare Provider Details

I. General information

NPI: 1811166549
Provider Name (Legal Business Name): WESTERN WAKE SURGICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2008
Last Update Date: 09/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 PARKWAY OFFICE CT SUITE 101
CARY NC
27518-7427
US

IV. Provider business mailing address

155 PARKWAY OFFICE CT SUITE 101
CARY NC
27518-7427
US

V. Phone/Fax

Practice location:
  • Phone: 919-859-4747
  • Fax: 919-859-4757
Mailing address:
  • Phone: 919-859-4747
  • Fax: 919-859-4757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number73992
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number73992
License Number StateNC

VIII. Authorized Official

Name: MRS. DEBRA L DAVIS
Title or Position: BILLING ADMINISTRATOR
Credential:
Phone: 919-859-4747