Basic Information
| Provider Information | |||||||||
| NPI: | 1184073280 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAKE SPECIALTY PHYSICIANS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WAKEMED RHEUMATOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602195 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193500554 | ||||||||
| FaxNumber: | 9193507687 | ||||||||
| Practice Location | |||||||||
| Address1: | 10010 FALLS OF NEUSE RD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276148494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192356450 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2016 | ||||||||
| LastUpdateDate: | 09/12/2016 | ||||||||
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| AuthorizedOfficialLastName: | JAYOUSSI | ||||||||
| AuthorizedOfficialFirstName: | MARIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR, FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 9193506089 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RR0500X | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
| ID | Type | State | Issuer | Description | 1942440375 | 05 | NC | MEDICAID |