Provider Demographics
NPI:1942489695
Name:WAKE FOREST UNIVERSITY BAPTIST MEDICAL CENTER COMMUNITY PHYSICIANS
Entity Type:Organization
Organization Name:WAKE FOREST UNIVERSITY BAPTIST MEDICAL CENTER COMMUNITY PHYSICIANS
Other - Org Name:CLUB HAVEN FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:LEWIS
Authorized Official - Middle Name:S
Authorized Official - Last Name:THORP
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:336-721-3900
Mailing Address - Street 1:2801 LYNDHURST AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4109
Mailing Address - Country:US
Mailing Address - Phone:336-768-9575
Mailing Address - Fax:336-774-1737
Practice Address - Street 1:2801 LYNDHURST AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4109
Practice Address - Country:US
Practice Address - Phone:336-768-9575
Practice Address - Fax:336-774-1737
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAKE FOREST UNIVERSITY BAPTIST MEDICAL CENTER COMMUNITY PHYSICIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-30
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5908389Medicaid
NC2317728XOtherMEDICARE GROUP NUMBER