Provider Demographics
NPI:1427604149
Name:WAKE SPECIALTY PHYSICIANS LLC
Entity Type:Organization
Organization Name:WAKE SPECIALTY PHYSICIANS LLC
Other - Org Name:WAKEMED PRIMARY CARE WEST CARY
Other - Org Type:Other Name
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:919-350-7485
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:919-350-0554
Mailing Address - Fax:919-350-7687
Practice Address - Street 1:7560 CARPENTER FIRE STATION RD
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27519-9637
Practice Address - Country:US
Practice Address - Phone:919-235-6545
Practice Address - Fax:919-235-6506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-19
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty