MEDICARE: WILKES PHYSICIAN NETWORK, INC.

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	207Q00000X	Family Medicine Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2335816	OTHER	NC	MEDICARE PTAN, GROUP

Other Identifiers

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

General Provider Information

NPI Number	:	1407177199
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILKES PHYSICIAN NETWORK, INC.

Provider Business Mailing Address
First Line	:	1534 W D ST
Second Line	:
City	:	NORTH WILKESBORO
State	:	NC
Zip	:	28659-3528
Country	:	US
Telephone Number	:	336-667-4178
Fax Number	:	336-667-0938

Provider Business Practice Location Address
First Line	:	1534 W D ST
Second Line	:
City	:	NORTH WILKESBORO
State	:	NC
Zip	:	28659-3528
Country	:	US
Telephone Number	:	336-667-4178
Fax Number	:	336-667-0938

Authorized Official
Title or Position	:	SR. VICE PRESIDENT
Name	:	FRIEDA M LOWDER
Credential	:
Telephone Number	:	704-403-4146

Provider Enumeration Date	:	06/16/2010
Last Update Date	:	03/02/2011

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