Provider Demographics
NPI:1386209633
Name:WAKEMED SPECIALISTS GROUP LLC
Entity Type:Organization
Organization Name:WAKEMED SPECIALISTS GROUP LLC
Other - Org Name:WAKEMED URGENT CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:VP, WPP 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:PO BOX 603949
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3949
Mailing Address - Country:US
Mailing Address - Phone:919-350-0552
Mailing Address - Fax:919-350-7687
Practice Address - Street 1:110 KILDAIRE PARK DR
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-8162
Practice Address - Country:US
Practice Address - Phone:919-859-1136
Practice Address - Fax:919-859-4240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-02
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1386209633Medicaid