Provider Demographics
NPI:1841956943
Name:WAKEMED SPECIALISTS GROUP LLC
Entity type:Organization
Organization Name:WAKEMED SPECIALISTS GROUP LLC
Other - Org Name:
Other - Org Type:
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: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:919-350-0351
Mailing Address - Fax:919-350-7687
Practice Address - Street 1:505 OBERLIN RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27605-1345
Practice Address - Country:US
Practice Address - Phone:919-882-6578
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-12
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCJ143OtherMEDICARE
NC1417512690Medicaid