Provider Demographics
NPI:1598320830
Name:WAKEMED SPECIALISTS GROUP, LLC
Entity Type:Organization
Organization Name:WAKEMED SPECIALISTS GROUP, LLC
Other - Org Name:WAKEMED UROGYNECOLOGY
Other - Org Type:Other Name
Authorized Official - Title/Position:VP, WPP
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 1:2920 HIGHWOODS BLVD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-0010
Mailing Address - Country:US
Mailing Address - Phone:919-350-0552
Mailing Address - Fax:919-350-7687
Practice Address - Street 1:10010 FALLS OF NEUSE RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-8494
Practice Address - Country:US
Practice Address - Phone:919-235-6509
Practice Address - Fax:919-235-6591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-02
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2088F0040XAllopathic & Osteopathic PhysiciansUrologyFemale Pelvic Medicine and Reconstructive SurgeryGroup - Multi-Specialty
No207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive SurgeryGroup - Multi-Specialty