Healthcare Provider Details

I. General information

NPI: 1992540686
Provider Name (Legal Business Name): WAKE SPECIALTY PHISICIANS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2024
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 NEW BERN AVE
RALEIGH NC
27610-1231
US

IV. Provider business mailing address

PO BOX 602195
CHARLOTTE NC
28260-2195
US

V. Phone/Fax

Practice location:
  • Phone: 919-350-8000
  • Fax:
Mailing address:
  • Phone:
  • 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: MICHAEL PAUL DUFFEY
Title or Position: EXEC DIRECTOR FINANCE
Credential:
Phone: 919-350-8000