Provider Demographics
NPI:1750685533
Name:WILKES PHYSICIAN NETWORK, INC.
Entity Type:Organization
Organization Name:WILKES PHYSICIAN NETWORK, INC.
Other - Org Name:WILKES ADULT AND PEDIATRIC MEDICINE
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 1:1915 WEST PARK DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:NORTH WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28659-3777
Mailing Address - Country:US
Mailing Address - Phone:336-838-9553
Mailing Address - Fax:336-838-9563
Practice Address - Street 1:1915 WEST PARK DR
Practice Address - Street 2:SUITE 103
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-3777
Practice Address - Country:US
Practice Address - Phone:336-838-9553
Practice Address - Fax:336-838-9563
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WILKES PHYSICIAN NETWORK, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-07
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5917190Medicaid
NC5917190Medicaid