Healthcare Provider Details

I. General information

NPI: 1225684004
Provider Name (Legal Business Name): WAKE SPECIALTY PHYSICIANS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2019
Last Update Date: 09/26/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 SIENA DR
WAKE FOREST NC
27587
US

IV. Provider business mailing address

PO BOX 602195
CHARLOTTE NC
28260-2195
US

V. Phone/Fax

Practice location:
  • Phone: 919-235-6540
  • Fax: 919-235-6504
Mailing address:
  • Phone: 919-350-0552
  • Fax: 919-350-7687

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: EXECUTIVE DIRECTOR FINANCE
Credential:
Phone: 919-350-8000