Healthcare Provider Details

I. General information

NPI: 1497307334
Provider Name (Legal Business Name): WAKEMED SPECIALISTS GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2019
Last Update Date: 08/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 SUNNYBROOK RD
RALEIGH NC
27610-1855
US

IV. Provider business mailing address

PO BOX 603949
CHARLOTTE NC
28260-3949
US

V. Phone/Fax

Practice location:
  • Phone: 919-235-6435
  • Fax: 919-231-0314
Mailing address:
  • Phone: 919-235-6435
  • Fax: 919-231-0314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number
License Number State

VIII. Authorized Official

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