Provider Demographics
NPI:1285865329
Name:WAYLAND W MCKENZIE MD PA
Entity Type:Organization
Organization Name:WAYLAND W MCKENZIE MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WAYLAND
Authorized Official - Middle Name:WILSON
Authorized Official - Last Name:MCKENZIE
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:336-273-8638
Mailing Address - Street 1:500 BANNER AVE STE A
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-3284
Mailing Address - Country:US
Mailing Address - Phone:336-273-8638
Mailing Address - Fax:336-274-0146
Practice Address - Street 1:500 BANNER AVE STE A
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-3284
Practice Address - Country:US
Practice Address - Phone:336-273-8638
Practice Address - Fax:336-274-0146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-06
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19760261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8957131Medicaid