Provider Demographics
NPI:1831500867
Name:WAKE SPECIALTY PHYSICIANS, LLC
Entity Type:Organization
Organization Name:WAKE SPECIALTY PHYSICIANS, LLC
Other - Org Name:WPP CAROLINA CARDIOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
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 1:2920 HIGHWOODS BLVD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-1015
Mailing Address - Country:US
Mailing Address - Phone:919-350-0552
Mailing Address - Fax:
Practice Address - Street 1:3324 SIX FORKS RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7233
Practice Address - Country:US
Practice Address - Phone:919-781-7772
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-13
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2347332Medicare PIN