Healthcare Provider Details

I. General information

NPI: 1275992455
Provider Name (Legal Business Name): WAKE SPECIALTY PHYSICIANS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2016
Last Update Date: 05/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10000 CAMBRIDGE VILLAGE LOOP
APEX NC
27502-7707
US

IV. Provider business mailing address

PO BOX 602195
CHARLOTTE NC
28260-2195
US

V. Phone/Fax

Practice location:
  • Phone: 919-629-8150
  • Fax: 919-350-1475
Mailing address:
  • Phone: 919-350-0552
  • Fax: 919-350-7687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier7108950011
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerDME PTAN

VIII. Authorized Official

Name: MARIA JAYOUSSI
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 919-350-6089