MEDICARE: WAKE FAMILY MEDICINE PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1215162466
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAKE FAMILY MEDICINE PC

Provider Business Mailing Address
First Line	:	1831 LAKE PINE DR STE 200
Second Line	:
City	:	CARY
State	:	NC
Zip	:	27511-6050
Country	:	US
Telephone Number	:	919-380-1849
Fax Number	:	919-380-1851

Provider Business Practice Location Address
First Line	:	1831 LAKE PINE DR STE 200
Second Line	:
City	:	CARY
State	:	NC
Zip	:	27511-6050
Country	:	US
Telephone Number	:	919-380-1849
Fax Number	:	919-380-1851

Authorized Official
Title or Position	:	OWNER/PHYSICAN
Name	:	DR. MRINALINI SUJALA KODUMAGULLA
Credential	:	MD
Telephone Number	:	919-395-3491

Provider Enumeration Date	:	05/18/2009
Last Update Date	:	09/30/2019

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