Provider Demographics
NPI:1124094008
Name:WAKEMED
Entity type:Organization
Organization Name:WAKEMED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR VP OF FINANCE AND CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:DEVAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:919-350-8000
Mailing Address - Street 1:400 W RANSOM ST
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-2434
Mailing Address - Country:US
Mailing Address - Phone:919-350-4600
Mailing Address - Fax:
Practice Address - Street 1:400 W RANSOM ST
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-2434
Practice Address - Country:US
Practice Address - Phone:919-350-4600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAKEMED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-02-28
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCH0276314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3405308Medicaid
NC3496096Medicaid
NC0093COtherBLUE CROSS
NC=========0002OtherCOMMERCIAL
NC0093COtherBLUE CROSS
NC3405308Medicaid
345308AMedicare Oscar/Certification