Provider Demographics
NPI:1871658443
Name:WAVERLY HEMATOLOGY ONCOLOGY PA
Entity Type:Organization
Organization Name:WAVERLY HEMATOLOGY ONCOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:919-233-8585
Mailing Address - Street 1:300 ASHVILLE AVE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-8682
Mailing Address - Country:US
Mailing Address - Phone:919-233-8585
Mailing Address - Fax:919-233-8566
Practice Address - Street 1:300 ASHVILLE AVE
Practice Address - Street 2:SUITE 310
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-8682
Practice Address - Country:US
Practice Address - Phone:919-233-8585
Practice Address - Fax:919-233-8566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC39812207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC138AHOtherBLUE CROSS
NC89138AHMedicaid
NCP00403727OtherPALMETTO GBA
NC138AHOtherBLUE CROSS
NCP00403727OtherPALMETTO GBA
2381116Medicare PIN