Provider Demographics
NPI:1316930654
Name:WAKE FOREST UNIVERSITY BAPTIST MEDICAL CENTER COMMUNITY PHYSICIANS
Entity type:Organization
Organization Name:WAKE FOREST UNIVERSITY BAPTIST MEDICAL CENTER COMMUNITY PHYSICIANS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LEWIS
Authorized Official - Middle Name:S
Authorized Official - Last Name:THORP
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:336-721-3900
Mailing Address - Street 1:7990 NORTH POINT BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-3259
Mailing Address - Country:US
Mailing Address - Phone:336-896-1100
Mailing Address - Fax:336-896-1146
Practice Address - Street 1:7990 NORTH POINT BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3259
Practice Address - Country:US
Practice Address - Phone:336-896-1100
Practice Address - Fax:336-896-1146
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAKE FOREST UNIVERSITY BAPTIST MEDICAL CENTER COMMUNITY PHYSICIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-23
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2317728HOtherMEDICARE GROUP NUMBER
NC890244TMedicaid