=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871780148
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WAKE FOREST UNIVERSITY BAPTIST MEDICAL CENTER COMMUNITY PHYSICIANS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2007
-----------------------------------------------------
Last Update Date | 10/01/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5391 US HIGHWAY 158
-----------------------------------------------------
City | ADVANCE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27006-6907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-940-2290
-----------------------------------------------------
Fax | 336-940-2561
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5391 US HIGHWAY 158
-----------------------------------------------------
City | ADVANCE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27006-6907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-940-2290
-----------------------------------------------------
Fax | 336-940-2561
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | LEWIS S THORP III
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 336-721-3900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------