Healthcare Provider Details

I. General information

NPI: 1598011173
Provider Name (Legal Business Name): WAKE SPECIALTY PHYSICIANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2012
Last Update Date: 08/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 RIDGE VIEW DR SUITE 105
CARY NC
27511-5589
US

IV. Provider business mailing address

3024 NEW BERN AVE
RALEIGH NC
27610-1247
US

V. Phone/Fax

Practice location:
  • Phone: 919-859-7044
  • Fax:
Mailing address:
  • Phone: 919-350-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SUSAN TUCKER WEAVER
Title or Position: EXECUTIVE VICE PRESIDENT
Credential: MD
Phone: 919-350-8228