Provider Demographics
NPI:1790752236
Name:WAKEMED
Entity Type:Organization
Organization Name:WAKEMED
Other - Org Name:WAKEMED RALEIGH CAMPUS REHABILITATION UNIT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VP OF FINANCE AND CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:DEVAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:919-350-8000
Mailing Address - Street 1:3000 NEW BERN AVE
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-1231
Mailing Address - Country:US
Mailing Address - Phone:919-350-7876
Mailing Address - Fax:
Practice Address - Street 1:3000 NEW BERN AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1231
Practice Address - Country:US
Practice Address - Phone:919-350-7876
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAKEMED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-03
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCH0199273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC00047OtherBLUE CROSS
NC3400069TMedicaid
NC010OtherCHAMPUS
NC3400069TMedicaid
NC34-T069Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
NC34T069Medicare Oscar/Certification
NC00047OtherBLUE CROSS