Basic Information
| Provider Information | |||||||||
| NPI: | 1245820091 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WAKE SPECIALTY PHYSICIANS LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WAKEMED MYCARE 365 PRIMARY & URGENT CARE WAKE FOREST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602195 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193500552 | ||||||||
| FaxNumber: | 9193507687 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 S MAIN ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | WAKE FOREST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275871652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193500365 | ||||||||
| FaxNumber: | 9192351307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2021 | ||||||||
| LastUpdateDate: | 01/28/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRINK | ||||||||
| AuthorizedOfficialFirstName: | SHONDRA | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | VP, WPP OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 9193506045 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QU0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 1346852407 | 05 | NC | MEDICAID |