Healthcare Provider Details

I. General information

NPI: 1215348156
Provider Name (Legal Business Name): WAKE SPECIALTY PHYSICIANS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2014
Last Update Date: 10/07/2025
Certification Date: 10/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 HEALTHPLEX WAY
APEX NC
27502-8403
US

IV. Provider business mailing address

PO BOX 602195
CHARLOTTE NC
28260-2195
US

V. Phone/Fax

Practice location:
  • Phone: 919-350-0550
  • Fax: 919-363-7722
Mailing address:
  • Phone: 919-350-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KAREN REVICKI PERRY
Title or Position: SLED
Credential:
Phone: 919-350-8000