MEDICARE: WAKE SPECIALTY PHYSICIANS LLC

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1427604149
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAKE SPECIALTY PHYSICIANS LLC

Provider Business Mailing Address
First Line	:	PO BOX 602195
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-2195
Country	:	US
Telephone Number	:	919-350-0554
Fax Number	:	919-350-7687

Provider Business Practice Location Address
First Line	:	7560 CARPENTER FIRE STATION RD
Second Line	:
City	:	CARY
State	:	NC
Zip	:	27519-9637
Country	:	US
Telephone Number	:	919-235-6545
Fax Number	:	919-235-6506

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR OF FINANCE
Name	:	MARIA JAYOUSSI
Credential	:
Telephone Number	:	919-350-7485

Provider Enumeration Date	:	08/19/2019
Last Update Date	:	10/16/2019

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