MEDICARE: WAKEMED SPECIALISTS GROUP, 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	207RA0001X	Advanced Heart Failure and Transplant Cardiology Physician

General Provider Information

NPI Number	:	1437713914
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAKEMED SPECIALISTS GROUP, LLC

Provider Business Mailing Address
First Line	:	2920 HIGHWOODS BLVD
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27604-0010
Country	:	US
Telephone Number	:	919-350-0552
Fax Number	:	919-350-7687

Provider Business Practice Location Address
First Line	:	3000 NEW BERN AVE
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27610-1231
Country	:	US
Telephone Number	:	919-350-7600
Fax Number	:	919-235-6583

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR OF FINANCE
Name	:	MARIA JAYOUSSI
Credential	:
Telephone Number	:	919-350-6089

Provider Enumeration Date	:	04/30/2019
Last Update Date	:	04/30/2019

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