Provider Demographics
NPI:1942301601
Name:WAKEFIELD MEDICAL INC
Entity Type:Organization
Organization Name:WAKEFIELD MEDICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:SHEARIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-570-5277
Mailing Address - Street 1:123 CAPCOM AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-6517
Mailing Address - Country:US
Mailing Address - Phone:919-570-5277
Mailing Address - Fax:919-570-5377
Practice Address - Street 1:123 CAPCOM AVE STE 3
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-6517
Practice Address - Country:US
Practice Address - Phone:919-570-5277
Practice Address - Fax:919-570-5377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00838332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7703955Medicaid
NC046XYOtherBCBSNC
NC7703955Medicaid