=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871797688
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WAKE FOREST UNIVERSITY BAPTIST MEDICAL CENTER COMMUNITY PHYSICIANS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2007
-----------------------------------------------------
Last Update Date | 04/10/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5175 OLD CLEMMONS SCHOOL ROAD
-----------------------------------------------------
City | CLEMMONS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-778-0200
-----------------------------------------------------
Fax | 336-778-0202
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5175 OLD CLEMMONS SCHOOL ROAD
-----------------------------------------------------
City | CLEMMONS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27012-9394
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-778-0200
-----------------------------------------------------
Fax | 336-778-0202
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT CEO
-----------------------------------------------------
Name | MR. 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 |
-----------------------------------------------------