Provider Demographics
NPI:1194964379
Name:WAKE FOREST UNIVERSITY HEALTH SCIENCES
Entity type:Organization
Organization Name:WAKE FOREST UNIVERSITY HEALTH SCIENCES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & COO, WFU HEALTH SCIENCE
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:SIBERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-716-2255
Mailing Address - Street 1:PO BOX 602598
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2598
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 N ELM ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1004
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAKE FOREST UNIVERSITY HEALTH SCIENCES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-12
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207P00000X, 261QM1300X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty