Basic Information
| Provider Information | |||||||||
| NPI: | 1326681164 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAKEMED SPECIALISTS GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 603949 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282603949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193500554 | ||||||||
| FaxNumber: | 9193507687 | ||||||||
| Practice Location | |||||||||
| Address1: | 2930 FORESTVILLE RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276168774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192356500 | ||||||||
| FaxNumber: | 9192356585 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2019 | ||||||||
| LastUpdateDate: | 10/24/2019 | ||||||||
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| AuthorizedOfficialLastName: | JAYOUSSI | ||||||||
| AuthorizedOfficialFirstName: | MARIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 9193506089 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 1386209633 | 05 | NC | MEDICAID |