Basic Information
| Provider Information | |||||||||
| NPI: | 1346501673 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WAKE SPECIALTY PHYSICIANS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WAKEMED PRIMARY CARE GARNER | ||||||||
| 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: | |||||||||
| City: | GARNER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275294049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192356400 | ||||||||
| FaxNumber: | 9193509835 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2012 | ||||||||
| LastUpdateDate: | 10/30/2017 | ||||||||
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| AuthorizedOfficialLastName: | JAYOUSSI | ||||||||
| AuthorizedOfficialFirstName: | MARIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 9193506089 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WAKE SPECIALTY PHYSICIANS LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1346501673 | 05 | NC | MEDICAID |