Basic Information
Provider Information | |||||||||
NPI: | 1114582301 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WAKEMED SPECIALISTS GROUP, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
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Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
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OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2920 HIGHWOODS BLVD | ||||||||
Address2: |   | ||||||||
City: | RALEIGH | ||||||||
State: | NC | ||||||||
PostalCode: | 276040010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9193500552 | ||||||||
FaxNumber: | 9193507687 | ||||||||
Practice Location | |||||||||
Address1: | 10010 FALLS OF NEUSE RD STE 9 | ||||||||
Address2: |   | ||||||||
City: | RALEIGH | ||||||||
State: | NC | ||||||||
PostalCode: | 276148495 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9193501508 | ||||||||
FaxNumber: | 9193501475 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/03/2019 | ||||||||
LastUpdateDate: | 05/03/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JAYOUSSI | ||||||||
AuthorizedOfficialFirstName: | MARIA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR OF FINANCE | ||||||||
AuthorizedOfficialTelephone: | 9193506089 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
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NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 225X00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   | 332B00000X |   |   | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
No ID Information.