Provider Demographics
NPI:1326681164
Name:WAKEMED SPECIALISTS GROUP, LLC
Entity Type:Organization
Organization Name:WAKEMED SPECIALISTS GROUP, LLC
Other - Org Name:
Other - Org Type:
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 603949
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3949
Mailing Address - Country:US
Mailing Address - Phone:919-350-0554
Mailing Address - Fax:919-350-7687
Practice Address - Street 1:2930 FORESTVILLE RD STE 100
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:919-235-6500
Practice Address - Fax:919-235-6585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-24
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1386209633Medicaid