Provider Demographics
NPI:1760523260
Name:WESTERN WAKE INTERNAL MEDICINE
Entity Type:Organization
Organization Name:WESTERN WAKE INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VIJAYA
Authorized Official - Middle Name:
Authorized Official - Last Name:POLAVARAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-870-0197
Mailing Address - Street 1:2025 GIOVANNI CT
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-7106
Mailing Address - Country:US
Mailing Address - Phone:919-319-6610
Mailing Address - Fax:919-319-6365
Practice Address - Street 1:907 KILDAIRE FARM RD
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-3922
Practice Address - Country:US
Practice Address - Phone:919-319-6610
Practice Address - Fax:919-319-6365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCH22020Medicare UPIN
NCH07946Medicare UPIN
2348014Medicare PIN