Provider Demographics
NPI:1346852407
Name:WAKE SPECIALTY PHYSICIANS
Entity Type:Organization
Organization Name:WAKE SPECIALTY PHYSICIANS
Other - Org Name:WAKEMED MYCARE 365 PRIMARY & URGENT CARE WAKE FOREST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:SHONDRA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BRINK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-350-6045
Mailing Address - Street 1:2001 S MAIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-1652
Mailing Address - Country:US
Mailing Address - Phone:919-235-6540
Mailing Address - Fax:919-235-6504
Practice Address - Street 1:2001 S MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-1652
Practice Address - Country:US
Practice Address - Phone:919-235-6540
Practice Address - Fax:919-235-6504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-20
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty