Provider Demographics
NPI:1598071524
Name:WAKEMED FACULTY PRACTICE PLAN
Entity Type:Organization
Organization Name:WAKEMED FACULTY PRACTICE PLAN
Other - Org Name:WAKEMED FACULTY PHYSICIANS - RALEIGH CARDIOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:TUCKER
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-350-8228
Mailing Address - Street 1:3000 NEW BERN AVE
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-1245
Mailing Address - Country:US
Mailing Address - Phone:919-231-6132
Mailing Address - Fax:919-231-6276
Practice Address - Street 1:3000 NEW BERN AVE
Practice Address - Street 2:SUITE 1200
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1245
Practice Address - Country:US
Practice Address - Phone:919-231-6132
Practice Address - Fax:919-231-6276
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAKEMED FACULTY PRACTICE PLAN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-27
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty