Provider Demographics
NPI:1013297365
Name:WAKE SPECIALTY PHYSICIANS, LLC
Entity type:Organization
Organization Name:WAKE SPECIALTY PHYSICIANS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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: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 1:212 ASHVILLE AVE
Practice Address - Street 2:SUITE 10
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-6669
Practice Address - Country:US
Practice Address - Phone:919-859-1136
Practice Address - Fax:919-859-4240
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAKE SPECIALTY PHYSICIANS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-18
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1013297365Medicaid
NC1013297365Medicaid