Healthcare Provider Details

I. General information

NPI: 1922091271
Provider Name (Legal Business Name): WAKE FOREST UNIVERSITY BAPTIST MEDICAL CENTER COMMUNITY PHYSICIANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 04/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3746 VEST MILL RD
WINSTON SALEM NC
27103-2912
US

IV. Provider business mailing address

3746 VEST MILL RD
WINSTON SALEM NC
27103-2912
US

V. Phone/Fax

Practice location:
  • Phone: 336-774-0710
  • Fax: 336-774-0707
Mailing address:
  • Phone: 336-774-0710
  • Fax: 336-774-0707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier890290N
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: MR. LEWIS S THORP III
Title or Position: PRESIDENT CEO
Credential:
Phone: 336-721-3900