Provider Demographics
NPI:1649827577
Name:WIREGRASS DIRECT PRIMARY CARE PLLC
Entity type:Organization
Organization Name:WIREGRASS DIRECT PRIMARY CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:IPOCK
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:813-999-0505
Mailing Address - Street 1:2236 GREEN HEDGES WAY
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544-8189
Mailing Address - Country:US
Mailing Address - Phone:813-999-0505
Mailing Address - Fax:813-701-9450
Practice Address - Street 1:2236 GREEN HEDGES WAY
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-8189
Practice Address - Country:US
Practice Address - Phone:813-999-0505
Practice Address - Fax:813-701-9450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-26
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Single Specialty
No332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105137300Medicaid