Healthcare Provider Details

I. General information

NPI: 1306260021
Provider Name (Legal Business Name): SOL MEDICAL GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2014
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 WAIT AVE
WAKE FOREST NC
27587
US

IV. Provider business mailing address

401 WAIT AVE
WAKE FOREST NC
27587-2725
US

V. Phone/Fax

Practice location:
  • Phone: 919-883-2108
  • Fax:
Mailing address:
  • Phone: 919-883-2108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number198788
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SOLA OGUNNIYI
Title or Position: PHYSICIAN ASSISTANT
Credential: PA-C
Phone: 919-883-2108