MEDICARE: WAKE FOREST BAPTIST IMAGING LLC

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	293D00000X	Physiological Laboratory
2	2085R0202X	Diagnostic Radiology Physician

General Provider Information

NPI Number	:	1841049913
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAKE FOREST BAPTIST IMAGING LLC

Provider Business Mailing Address
First Line	:	PO BOX 1000 DEPT 842
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38148-0842
Country	:	US
Telephone Number	:	615-261-2306
Fax Number	:	855-588-3545

Provider Business Practice Location Address
First Line	:	3120 NORTHLINE AVE STE 3120-101
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27408-7814
Country	:	US
Telephone Number	:	336-765-5722
Fax Number	:	336-765-5723

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	AMY STOUT
Credential	:
Telephone Number	:	615-261-2306

Provider Enumeration Date	:	05/13/2024
Last Update Date	:	10/21/2024

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