Provider Demographics
NPI:1275692667
Name:WAKE UROLOGICAL ASSOCIATES, P.A.
Entity Type:Organization
Organization Name:WAKE UROLOGICAL ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:MOUNTFORD
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:919-782-1255
Mailing Address - Street 1:4301 LAKE BOONE TRL
Mailing Address - Street 2:SUITE 300
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-7507
Mailing Address - Country:US
Mailing Address - Phone:919-782-1255
Mailing Address - Fax:919-782-6056
Practice Address - Street 1:4301 LAKE BOONE TRL
Practice Address - Street 2:SUITE 300
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7507
Practice Address - Country:US
Practice Address - Phone:919-782-1255
Practice Address - Fax:919-782-6056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200001388680208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC01928OtherBCBS GROUP NUMBER
NC8901928Medicaid
NC0304820001Medicare NSC
NC01928OtherBCBS GROUP NUMBER
NCCL4978Medicare ID - Type UnspecifiedRAILROAD MEDICARE GROUP