Basic Information
| Provider Information | |||||||||
| NPI: | 1649741950 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAKE SPECIALTY PHYSICIANS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TRIANGLE SINUS CENTER | ||||||||
| 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: | 10010 FALLS OF NEUSE RD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276148494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197668989 | ||||||||
| FaxNumber: | 9197668896 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2018 | ||||||||
| LastUpdateDate: | 02/27/2019 | ||||||||
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| AuthorizedOfficialLastName: | JAYOUSSI | ||||||||
| AuthorizedOfficialFirstName: | MARIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXEC. VP OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 9193500554 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 1942440375 | 05 | NC | MEDICAID |