Healthcare Provider Details

I. General information

NPI: 1598320830
Provider Name (Legal Business Name): WAKEMED SPECIALISTS GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2019
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10010 FALLS OF NEUSE RD
RALEIGH NC
27614-8494
US

IV. Provider business mailing address

2920 HIGHWOODS BLVD
RALEIGH NC
27604-0010
US

V. Phone/Fax

Practice location:
  • Phone: 919-235-6509
  • Fax: 919-235-6591
Mailing address:
  • Phone: 919-350-0552
  • Fax: 919-350-7687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2088F0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Urology) Physician
License Number
License Number State

VIII. Authorized Official

Name: SHONDRA LYNN BRINK
Title or Position: VP, WPP
Credential:
Phone: 919-350-6045