Basic Information
| Provider Information | |||||||||
| NPI: | 1639734817 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAKEMED SPECIALISTS GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2920 HIGHWOODS BLVD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276040010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193500552 | ||||||||
| FaxNumber: | 9193507687 | ||||||||
| Practice Location | |||||||||
| Address1: | 3024 NEW BERN AVE | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276101247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193502800 | ||||||||
| FaxNumber: | 9193505701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2019 | ||||||||
| LastUpdateDate: | 05/03/2019 | ||||||||
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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 | 133NN1002X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Nutritionist | Nutrition, Education | 133V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.