Provider Demographics
NPI:1659602449
Name:WILKES PHYSICIAN NETWORK, INC.
Entity Type:Organization
Organization Name:WILKES PHYSICIAN NETWORK, INC.
Other - Org Name:WILKES REGIONAL GASTROENTEROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VP
Authorized Official - Prefix:
Authorized Official - First Name:FRIEDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:LOWDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-403-4146
Mailing Address - Street 1:1404 WILLOW LN
Mailing Address - Street 2:WILKES REGIONAL GASTROENTEROLOGY
Mailing Address - City:NORTH WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28659-3584
Mailing Address - Country:US
Mailing Address - Phone:336-651-3603
Mailing Address - Fax:336-651-3610
Practice Address - Street 1:1404 WILLOW LN
Practice Address - Street 2:WILKES REGIONAL GASTROENTEROLOGY
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-3584
Practice Address - Country:US
Practice Address - Phone:336-651-3603
Practice Address - Fax:336-651-3610
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WILKES PHYSICIAN NETWORK, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-19
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5914561Medicaid
NC2335816OtherMEDICARE PTAN