Basic Information
| Provider Information | |||||||||
| NPI: | 1093184368 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAKE SPECIALTY PHYSICIANS LLC | ||||||||
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| OtherOrganizationName: | WAKEMED WAKE ORTHOPAEDICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602195 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193500552 | ||||||||
| FaxNumber: | 9193507687 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 US HIGHWAY 70 EAST | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | GARNER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275294049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192325020 | ||||||||
| FaxNumber: | 9192325021 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2015 | ||||||||
| LastUpdateDate: | 12/31/2015 | ||||||||
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| AuthorizedOfficialLastName: | JAYOUSSI | ||||||||
| AuthorizedOfficialFirstName: | MARIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 9193506089 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 1942440375 | 05 | NC | MEDICAID | 7108950004 | 01 | NC | DME PTAN | OTHER |