Healthcare Provider Details

I. General information

NPI: 1205491495
Provider Name (Legal Business Name): WAKEMED SPECIALISTS GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2019
Last Update Date: 08/21/2019
Certification Date:
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 603949
CHARLOTTE NC
28260-3949
US

V. Phone/Fax

Practice location:
  • Phone: 919-232-5202
  • Fax: 919-350-9844
Mailing address:
  • Phone: 919-350-0552
  • Fax: 919-350-7687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MARIA JAYOUSSI
Title or Position: EXECUTIVE DIRECTOR OF FINANCE
Credential:
Phone: 919-350-6089