Provider Demographics
NPI:1174086441
Name:WAKE EMERGENCY PHYSICIANS PA
Entity type:Organization
Organization Name:WAKE EMERGENCY PHYSICIANS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:RALEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-859-3373
Mailing Address - Street 1:PO BOX 890053
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-0053
Mailing Address - Country:US
Mailing Address - Phone:855-691-9890
Mailing Address - Fax:919-350-8874
Practice Address - Street 1:509 N BRIGHTLEAF BLVD
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-4407
Practice Address - Country:US
Practice Address - Phone:919-934-8171
Practice Address - Fax:919-336-4363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-12
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2319661AOtherMEDICARE
NCCD5224OtherRAILROAD MEDICARE
NC0295FOtherBCBS