Basic Information
| Provider Information | |||||||||
| NPI: | 1225417132 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WAKE SPECIALTY PHYSICIANS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | WAKEMED WORKSITE CORPORATE | ||||||||
| 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: | 3024 NEW BERN AVE | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276101247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193500552 | ||||||||
| FaxNumber: | 9193507687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2015 | ||||||||
| LastUpdateDate: | 05/26/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JAYOUSSI | ||||||||
| AuthorizedOfficialFirstName: | MARIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXEC DIRECTOR, FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 9193506089 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133NN1002X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Nutritionist | Nutrition, Education | 133V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1942440375 | 05 | NC | MEDICAID |