1053921874 NPI number — WAKE SPECIALTY PHISICIANS, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053921874 NPI number — WAKE SPECIALTY PHISICIANS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAKE SPECIALTY PHISICIANS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053921874
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 602195
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28260-2195
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-350-0554
Provider Business Mailing Address Fax Number:
919-350-7687

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 OBERLIN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27605-1126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-235-6566
Provider Business Practice Location Address Fax Number:
919-235-6532
Provider Enumeration Date:
08/06/2020

Additional Information

Authorized Official

Authorized Official Last Name:
BRINK
Authorized Official First Name:
SHONDRA
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
VP, WPP OPERATIONS
Authorized Official Telephone Number:
919-350-6045

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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