MEDICARE: WAKE SPECIALTY PHYSICIANS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician
2	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1396000188
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAKE SPECIALTY PHYSICIANS

Provider Business Mailing Address
First Line	:	3024 NEW BERN AVE
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27610-1247
Country	:	US
Telephone Number	:	919-350-8000
Fax Number	:

Provider Business Practice Location Address
First Line	:	6102 GRACE PARK DR
Second Line	:
City	:	MORRISVILLE
State	:	NC
Zip	:	27560-6003
Country	:	US
Telephone Number	:	919-235-6405
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE VICE PRESIDENT
Name	:	DR. SUSAN TUCKER WEAVER
Credential	:	MD
Telephone Number	:	919-350-8228

Provider Enumeration Date	:	07/09/2012
Last Update Date	:	07/09/2012

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