Provider Demographics
NPI:1942554019
Name:WAKE SPECIALTY PHYSICIANS
Entity Type:Organization
Organization Name:WAKE SPECIALTY PHYSICIANS
Other - Org Name:WSP-RALEIGH CARDIOLOGY
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 1:3000 NEW BERN AVE
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-1231
Mailing Address - Country:US
Mailing Address - Phone:919-231-6132
Mailing Address - Fax:
Practice Address - Street 1:555 MEDICAL PARK PL
Practice Address - Street 2:SUITE 110
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27520-2174
Practice Address - Country:US
Practice Address - Phone:919-861-8939
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAKE SPECIALTY PHYSICIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty