Provider Demographics
NPI:1588968184
Name:WAKEMED FACULTY PRACTICE PLAN
Entity type:Organization
Organization Name:WAKEMED FACULTY PRACTICE PLAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:TUCKER
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-350-8228
Mailing Address - Street 1:3324 SIX FORKS RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7233
Mailing Address - Country:US
Mailing Address - Phone:919-781-7772
Mailing Address - Fax:919-787-6331
Practice Address - Street 1:3324 SIX FORKS RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7233
Practice Address - Country:US
Practice Address - Phone:919-781-7772
Practice Address - Fax:919-787-6331
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAKEMED FACULTY PRACTICE PLAN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-12-23
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty