Provider Demographics
NPI:1619276318
Name:WAKEHEALTH MEDICAL GROUP, PA.
Entity Type:Organization
Organization Name:WAKEHEALTH MEDICAL GROUP, PA.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEFFERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-554-6754
Mailing Address - Street 1:13200 NEW FALLS OF NEUSE RD
Mailing Address - Street 2:STE 113
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-8239
Mailing Address - Country:US
Mailing Address - Phone:919-554-6754
Mailing Address - Fax:919-554-6756
Practice Address - Street 1:13200 NEW FALLS OF NEUSE RD
Practice Address - Street 2:STE 113
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-8239
Practice Address - Country:US
Practice Address - Phone:919-554-6754
Practice Address - Fax:919-554-6756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-21
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC138957174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty