=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023790524
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WAKE FOREST UNIVERSITY HEALTH SCIENCES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2023
-----------------------------------------------------
Last Update Date | 08/03/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 623 RADAR RD
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27410-6221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-668-4410
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 623 RADAR RD
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27410-6221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-668-4410
-----------------------------------------------------
Fax | 336-271-9669
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT, ATRIUM HEALTH WAKE FORES
-----------------------------------------------------
Name | KEVIN HIGH
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 336-713-4944
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------