Healthcare Provider Details

I. General information

NPI: 1841049913
Provider Name (Legal Business Name): WAKE FOREST BAPTIST IMAGING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2024
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3120 NORTHLINE AVE STE 3120-101
GREENSBORO NC
27408-7814
US

IV. Provider business mailing address

PO BOX 1000 DEPT 842
MEMPHIS TN
38148-0842
US

V. Phone/Fax

Practice location:
  • Phone: 336-765-5722
  • Fax: 336-765-5723
Mailing address:
  • Phone: 615-261-2306
  • Fax: 855-588-3545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State

VIII. Authorized Official

Name: AMY STOUT
Title or Position: PRESIDENT/CEO
Credential:
Phone: 615-261-2306