Healthcare Provider Details

I. General information

NPI: 1194964379
Provider Name (Legal Business Name): WAKE FOREST UNIVERSITY HEALTH SCIENCES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2009
Last Update Date: 06/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N ELM ST
GREENSBORO NC
27401-1004
US

IV. Provider business mailing address

PO BOX 602598
CHARLOTTE NC
28260-2598
US

V. Phone/Fax

Practice location:
  • Phone: 336-716-2255
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNC

VIII. Authorized Official

Name: THOMAS E SIBERT
Title or Position: PRESIDENT & COO, WFU HEALTH SCIENCE
Credential: MD
Phone: 336-716-2255