MEDICARE: NORTHSIDE DIALYSIS CENTER OF WAKE FOREST UNIVERSITY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center		NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114904133
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHSIDE DIALYSIS CENTER OF WAKE FOREST UNIVERSITY

Provider Business Mailing Address
First Line	:	PO BOX 7350
Second Line	:
City	:	TIFTON
State	:	GA
Zip	:	31793-7350
Country	:	US
Telephone Number	:	229-387-3528
Fax Number	:	229-386-2149

Provider Business Practice Location Address
First Line	:	500 W HANES MILL RD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27105-9814
Country	:	US
Telephone Number	:	336-744-0577
Fax Number	:	336-744-9021

Authorized Official
Title or Position	:	CREDENTIALING COORD.
Name	:	MS. KIMBERLY AGEE-CLARK JOHNSON
Credential	:	MBA
Telephone Number	:	229-387-3528

Provider Enumeration Date	:	12/30/2005
Last Update Date	:	02/09/2026

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