=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205080314
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAFAYETTE SLEEP LAB PULMONOLOGY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2008
-----------------------------------------------------
Last Update Date | 01/29/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1746 METROMEDICAL DR
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28304-3861
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-486-6550
-----------------------------------------------------
Fax | 910-321-2879
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1746 METROMEDICAL DR
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28304-3861
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-486-6550
-----------------------------------------------------
Fax | 910-321-2879
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. DOUGLAS WAYNE WHETSELL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 910-486-6550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RS0012X
-----------------------------------------------------
Taxonomy Name | Sleep Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | NC27754
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number | NC27754
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------