Provider Demographics
NPI:1326031543
Name:WAKE FOREST BAPTIST MEDICAL CENTER COMMUNITY PHYSICIANS
Entity Type:Organization
Organization Name:WAKE FOREST BAPTIST MEDICAL CENTER COMMUNITY PHYSICIANS
Other - Org Name:WINSTON EAST PEDIATRICS
Other - Org Type:Doing Business As
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 1:2295 EAST 14TH ST
Mailing Address - Street 2:STE 100
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27105
Mailing Address - Country:US
Mailing Address - Phone:336-725-0514
Mailing Address - Fax:336-725-2173
Practice Address - Street 1:2295 EAST 14TH ST
Practice Address - Street 2:STE 100
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105
Practice Address - Country:US
Practice Address - Phone:336-725-0514
Practice Address - Fax:336-725-2173
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:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2317728IOtherMEDICARE GROUP NUMBER
NC890228UMedicaid