Provider Demographics
NPI:1093184368
Name:WAKE SPECIALTY PHYSICIANS LLC
Entity Type:Organization
Organization Name:WAKE SPECIALTY PHYSICIANS LLC
Other - Org Name:WAKEMED WAKE ORTHOPAEDICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JAYOUSSI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-350-6089
Mailing Address - Street 1:PO BOX 602195
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2195
Mailing Address - Country:US
Mailing Address - Phone:919-350-0552
Mailing Address - Fax:919-350-7687
Practice Address - Street 1:400 US HIGHWAY 70 EAST
Practice Address - Street 2:SUITE 202
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-4049
Practice Address - Country:US
Practice Address - Phone:919-232-5020
Practice Address - Fax:919-232-5021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-17
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1942440375Medicaid
NC7108950004OtherDME PTAN
NC2347332Medicare PIN