=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730823170
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WAKE SPINE AND PAIN SPECIALISTS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2022
-----------------------------------------------------
Last Update Date | 04/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2573 STANTONSBURG RD STE A
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27834-7213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-787-7246
-----------------------------------------------------
Fax | 919-787-7247
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3801 WAKE FOREST RD STE 210
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27609-6864
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-787-7246
-----------------------------------------------------
Fax | 919-787-7247
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | VIJAYSINHA MANDHARE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 919-787-7246
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------