NPIMap

Organization Active NPI

Wake Specialty Physicians LLC

Doing business as WakeMed Primary Care Knightdale

  • Family Medicine Physician
  • Knightdale, NC
National Provider Identifier
1225449168
Registry record updated Aug 8, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
WAKE SPECIALTY PHYSICIANS LLC
Doing business as
WakeMed Primary Care Knightdale
Practice address
901 Old Knight Rd
Knightdale, NC 27545-9065
Phone
(919) 266-6211
Fax
(919) 350-9824
NPI assigned
May 14, 2014
Last updated
Aug 8, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 8, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Maria Jayoussi
Title
Executive Director of Finance
Phone
(919) 350-6089

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X NU Primary
Internal Medicine Physician 207R00000X NU

Addresses

Primary practice location

901 Old Knight Rd
Knightdale, NC 27545-9065

Mailing address

PO Box 602195
Charlotte, NC 28260-2195
Phone (919) 350-0554

Other identifiers 1

IdentifierTypeStateIssuer
1225449168MedicaidNC

Other names 1

  • WakeMed Primary Care Knightdale Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NC

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20090601000520 NC Part B Supplier - Clinic/Group Practice 7416006085 Receives reassigned benefits from 283 practitioners
43 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment

Other NPIs on the same Medicare enrollment 43

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 43

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
34D0891271Wakemed Primary Care - Knightdale901 Old Knight Road, Knightdale, NC 27545Certificate of waiverJan 30, 2027

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 8

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1400025600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1565222400000",
    "number": "1225449168",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 602195",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282602195",
            "telephone_number": "919-350-0554"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "901 OLD KNIGHT RD",
            "city": "KNIGHTDALE",
            "state": "NC",
            "postal_code": "275459065",
            "telephone_number": "919-266-6211",
            "fax_number": "919-350-9824"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAKE SPECIALTY PHYSICIANS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-05-14",
        "last_updated": "2019-08-08",
        "status": "A",
        "authorized_official_last_name": "JAYOUSSI",
        "authorized_official_first_name": "MARIA",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR OF FINANCE",
        "authorized_official_telephone_number": "919-350-6089"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1225449168",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "WakeMed Primary Care Knightdale",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Knightdale, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 8, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.