Healthcare Provider Details

I. General information

NPI: 1649827577
Provider Name (Legal Business Name): WIREGRASS DIRECT PRIMARY CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2019
Last Update Date: 04/11/2022
Certification Date: 04/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2236 GREEN HEDGES WAY
WESLEY CHAPEL FL
33544-8189
US

IV. Provider business mailing address

2236 GREEN HEDGES WAY
WESLEY CHAPEL FL
33544-8189
US

V. Phone/Fax

Practice location:
  • Phone: 813-999-0505
  • Fax: 813-701-9450
Mailing address:
  • Phone: 813-999-0505
  • Fax: 813-701-9450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: DENNIS MICHAEL IPOCK
Title or Position: MANAGER
Credential: APRN
Phone: 813-999-0505