Basic Information
| Provider Information | |||||||||
| NPI: | 1184202830 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAKEMED SPECIALISTS GROUP LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 603949 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282603949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193500552 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3024 NEW BERN AVE | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276101247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193507251 | ||||||||
| FaxNumber: | 9193501606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2021 | ||||||||
| LastUpdateDate: | 04/01/2021 | ||||||||
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| AuthorizedOfficialLastName: | BRINK | ||||||||
| AuthorizedOfficialFirstName: | SHONDRA | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | VP WPP OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 9193506045 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 2088P0231X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology |
No ID Information.