Healthcare Provider Details

I. General information

NPI: 1073424164
Provider Name (Legal Business Name): WAKE SPECIALTY PHYSICIANS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7921 YARDLY VILLAGE LANE
RALEIGH NC
27616
US

IV. Provider business mailing address

PO BOX 803854
KANSAS CITY MO
64180-3854
US

V. Phone/Fax

Practice location:
  • Phone: 919-350-0365
  • Fax:
Mailing address:
  • Phone: 877-498-4490
  • Fax: 919-350-7687

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

VIII. Authorized Official

Name: KAREN REVICKI PERRY
Title or Position: EXECUTIVE DIRECTOR OPERATIONS WPP
Credential:
Phone: 919-350-8000