Provider Demographics
NPI:1497204143
Name:WAKE SPECIALTY PHYSICIANS LLC
Entity Type:Organization
Organization Name:WAKE SPECIALTY PHYSICIANS LLC
Other - Org Name:WAKEMED PHYSICIAN PRACTICES GROUP HOME
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 1:2820 KIDD RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1842
Practice Address - Country:US
Practice Address - Phone:919-350-2800
Practice Address - Fax:919-350-8147
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAKEMED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-09-22
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 208000000X
NC315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1942440375Medicaid
NC1942440375Medicaid