Provider Demographics
NPI:1841243540
Name:WAKE ORTHOPAEDICS, LLC
Entity Type:Organization
Organization Name:WAKE ORTHOPAEDICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:PONTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-232-5020
Mailing Address - Street 1:3009 NEW BERN AVE
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-1214
Mailing Address - Country:US
Mailing Address - Phone:919-232-5020
Mailing Address - Fax:919-232-5021
Practice Address - Street 1:3009 NEW BERN AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1214
Practice Address - Country:US
Practice Address - Phone:919-232-5020
Practice Address - Fax:919-232-5021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2335768Medicare ID - Type Unspecified
6170650002Medicare NSC
6170650001Medicare NSC
NC6170650003Medicare NSC