Provider Demographics
NPI:1811166549
Name:WESTERN WAKE SURGICAL PC
Entity type:Organization
Organization Name:WESTERN WAKE SURGICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-859-4747
Mailing Address - Street 1:155 PARKWAY OFFICE CT
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-7427
Mailing Address - Country:US
Mailing Address - Phone:919-859-4747
Mailing Address - Fax:919-859-4757
Practice Address - Street 1:155 PARKWAY OFFICE CT
Practice Address - Street 2:SUITE 101
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-7427
Practice Address - Country:US
Practice Address - Phone:919-859-4747
Practice Address - Fax:919-859-4757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC73992208C00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1295YOtherBCBS
NC891295YMedicaid
NC1295YOtherBCBS
NC891295YMedicaid