Provider Demographics
NPI:1255851424
Name:WAKE SPECIALTY PHYSICIANS LLC
Entity Type:Organization
Organization Name:WAKE SPECIALTY PHYSICIANS LLC
Other - Org Name:WAKEMED PRIMARY CARE FORESTVILLE CROSSING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR OF 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 1:2930 FORESTVILLE RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-8774
Practice Address - Country:US
Practice Address - Phone:919-235-6550
Practice Address - Fax:919-235-6586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-20
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1255851424Medicaid