Provider Demographics
NPI:1598011173
Name:WAKE SPECIALTY PHYSICIANS
Entity Type:Organization
Organization Name:WAKE SPECIALTY PHYSICIANS
Other - Org Name:WSP WELLNESS FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:TUCKER
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-350-8228
Mailing Address - Street 1:3024 NEW BERN AVE
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-1247
Mailing Address - Country:US
Mailing Address - Phone:919-350-8000
Mailing Address - Fax:
Practice Address - Street 1:100 RIDGE VIEW DR
Practice Address - Street 2:SUITE 105
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-5589
Practice Address - Country:US
Practice Address - Phone:919-859-7044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAKE SPECIALTY PHYSICIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-01
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty