Healthcare Provider Details

I. General information

NPI: 1013203819
Provider Name (Legal Business Name): WAKEMED FACULTY PRACTICE PLAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2011
Last Update Date: 07/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3024 NEW BERN AVE
RALEIGH NC
27610-1247
US

IV. Provider business mailing address

3024 NEW BERN AVE
RALEIGH NC
27610-1247
US

V. Phone/Fax

Practice location:
  • Phone: 919-350-8000
  • Fax:
Mailing address:
  • Phone: 919-350-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SUSAN TUCKER WEAVER
Title or Position: SENIOR VICE PRESIDENT
Credential: M.D.
Phone: 919-350-8228