Provider Demographics
NPI:1265923205
Name:WAKE EMERGENCY PHYSICIANS PA
Entity type:Organization
Organization Name:WAKE EMERGENCY PHYSICIANS PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-348-4481
Mailing Address - Street 1:210 TOWNE VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513-8910
Mailing Address - Country:US
Mailing Address - Phone:919-859-3373
Mailing Address - Fax:919-336-4363
Practice Address - Street 1:210 TOWNE VILLAGE DR
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27513-8910
Practice Address - Country:US
Practice Address - Phone:919-859-3373
Practice Address - Fax:919-336-4363
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAKE EMERGENCY PHYSICIANS PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-25
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207P00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty