Healthcare Provider Details

I. General information

NPI: 1063076453
Provider Name (Legal Business Name): WAKEMED SPECIALISTS GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2019
Last Update Date: 07/23/2025
Certification Date: 07/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3024 NEW BERN AVE
RALEIGH NC
27610-1247
US

IV. Provider business mailing address

PO BOX 603949
CHARLOTTE NC
28260-3949
US

V. Phone/Fax

Practice location:
  • Phone: 919-350-1380
  • Fax: 919-556-0124
Mailing address:
  • Phone: 919-350-0552
  • Fax: 919-350-7687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number
License Number State

VIII. Authorized Official

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