1659934511 NPI number — WAKE SPECIALTY PHYSICIANS, LLC

Table of content: (NPI 1659934511)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659934511 NPI number — WAKE SPECIALTY PHYSICIANS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAKE SPECIALTY PHYSICIANS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WAKEMED CHILDREN'S-PEDIATRIC BEHAVIORAL HEALTH
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659934511
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/24/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 602195
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28260-2195
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-498-4490
Provider Business Mailing Address Fax Number:
919-350-7687

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23 SUNNYBROOK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27610-1855
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-350-8797
Provider Business Practice Location Address Fax Number:
919-350-7859
Provider Enumeration Date:
04/17/2019

Additional Information

Authorized Official

Authorized Official Last Name:
JAYOUSSI
Authorized Official First Name:
MARIA
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE VP OF FINANCE
Authorized Official Telephone Number:
919-350-0554

Provider Taxonomy Codes

  • Taxonomy code: 2080P0006X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1942440375 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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