Healthcare Provider Details

I. General information

NPI: 1821736075
Provider Name (Legal Business Name): WAKEMED SPECIALISTS GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2022
Last Update Date: 05/26/2022
Certification Date: 05/10/2022
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: 919-350-7331
  • Fax:
Mailing address:
  • Phone: 919-350-0554
  • Fax: 919-350-7687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

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