Provider Demographics
NPI:1275992455
Name:WAKE SPECIALTY PHYSICIANS LLC
Entity Type:Organization
Organization Name:WAKE SPECIALTY PHYSICIANS LLC
Other - Org Name:WAKEMED PHYSICIAN PRACTICES PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
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 1:10000 CAMBRIDGE VILLAGE LOOP
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-7707
Practice Address - Country:US
Practice Address - Phone:919-629-8150
Practice Address - Fax:919-350-1475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-17
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7108950011OtherDME PTAN
NC7108950011OtherDME PTAN