Healthcare Provider Details

I. General information

NPI: 1942554019
Provider Name (Legal Business Name): WAKE SPECIALTY PHYSICIANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2012
Last Update Date: 10/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 MEDICAL PARK PL SUITE 110
CLAYTON NC
27520-2174
US

IV. Provider business mailing address

3000 NEW BERN AVE SUITE 1200
RALEIGH NC
27610-1231
US

V. Phone/Fax

Practice location:
  • Phone: 919-861-8939
  • Fax:
Mailing address:
  • Phone: 919-231-6132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology 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