Provider Demographics
NPI:1538123450
Name:WAKE RADIOLOGY DIAGNOSTIC IMAGING, INC.
Entity Type:Organization
Organization Name:WAKE RADIOLOGY DIAGNOSTIC IMAGING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:WILCOX
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, MHA
Authorized Official - Phone:919-787-8221
Mailing Address - Street 1:PO BOX 19368
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27619-9368
Mailing Address - Country:US
Mailing Address - Phone:919-787-8221
Mailing Address - Fax:919-881-2079
Practice Address - Street 1:3949 BROWNING PL
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6536
Practice Address - Country:US
Practice Address - Phone:919-787-8221
Practice Address - Fax:919-881-2079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-17
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty
No2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic NeuroimagingGroup - Multi-Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Multi-Specialty
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric RadiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCCC3796OtherRAILROAD MEDICARE
NC7902834Medicaid
NC7092257OtherAETNA
NCCC3796OtherRAILROAD MEDICARE
NC7902834Medicaid
NC7902834Medicaid