1063076453 NPI number — WAKEMED SPECIALISTS GROUP LLC

Table of content: (NPI 1063076453)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063076453 NPI number — WAKEMED SPECIALISTS GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAKEMED SPECIALISTS GROUP 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 OBSTETRICS & GYNECOLOGY
Provider Other Organization Name Type Code:
5
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:
1063076453
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 603949
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:
28260-3949
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-350-0552
Provider Business Mailing Address Fax Number:
919-350-7687

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10010 FALLS OF NEUSE 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:
27614-8494
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-350-1380
Provider Business Practice Location Address Fax Number:
919-556-0124
Provider Enumeration Date:
05/01/2019

Additional Information

Authorized Official

Authorized Official Last Name:
JAYOUSSI
Authorized Official First Name:
MARIA
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR OF FINANCE
Authorized Official Telephone Number:
919-350-6089

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207VG0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207VX0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1063076453 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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