Provider Demographics
NPI:1417940636
Name:WAKE FOREST UNIVERSITY BAPTIST MEDICAL CENTER COMMUNITY PHYSICIANS
Entity Type:Organization
Organization Name:WAKE FOREST UNIVERSITY BAPTIST MEDICAL CENTER COMMUNITY PHYSICIANS
Other - Org Name:YOUNG FAMILY PRACTICE
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:336-659-5116
Mailing Address - Street 1:509 BROOKDALE DR
Mailing Address - Street 2:YOUNG FAMILY PRACTICE
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-4107
Mailing Address - Country:US
Mailing Address - Phone:704-924-7992
Mailing Address - Fax:704-924-7950
Practice Address - Street 1:509 BROOKDALE DR
Practice Address - Street 2:YOUNG FAMILY PRACTICE
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-4107
Practice Address - Country:US
Practice Address - Phone:704-924-7992
Practice Address - Fax:704-924-7950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89015T3Medicaid
NC89015T3Medicaid