Provider Demographics
NPI:1144279001
Name:DIALYSIS ACCESS GROUP OF WAKE FOREST UNIVERSITY, LLC
Entity type:Organization
Organization Name:DIALYSIS ACCESS GROUP OF WAKE FOREST UNIVERSITY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:HALES
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:336-716-3003
Mailing Address - Street 1:PO BOX 20516
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27120-0516
Mailing Address - Country:US
Mailing Address - Phone:229-387-3527
Mailing Address - Fax:229-386-2149
Practice Address - Street 1:120 MILLER STREET
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2500
Practice Address - Country:US
Practice Address - Phone:336-723-1080
Practice Address - Fax:336-722-3040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5916155Medicaid
VA1144279001Medicaid
NC5905783Medicaid
NC2327747Medicare PIN