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NPI Code Detail

MEDICARE: WILMINGTON MEDICAL GROUP PA

MEDICARE: WILMINGTON MEDICAL GROUP PA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine Physician

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1230038OTHERNCMEDICARE

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3012TPOTHERNCBCBS

General Provider Information

NPI Number : 1104962612
Entity Type Code : Organization
Provider Name (Legal Business Name) : WILMINGTON MEDICAL GROUP PA
Provider Business Mailing Address
First Line : 1925A OLEANDER DR
Second Line :
City : WILMINGTON
State : NC
Zip : 28403-2334
Country : US
Telephone Number : 910-251-8851
Fax Number : 910-251-7777
Provider Business Practice Location Address
First Line : 614 N JK POWELL BLVD
Second Line :
City : WHITEVILLE
State : NC
Zip : 28472-3008
Country : US
Telephone Number : 910-640-2009
Fax Number : 910-251-7777
Authorized Official
Title or Position : MEDICAL DIRECTOR
Name : JAMES HENRY PRIDGEN
Credential : M.D.
Telephone Number : 910-640-2009
Provider Enumeration Date : 01/30/2007
Last Update Date : 11/20/2007

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Directions to “WILMINGTON MEDICAL GROUP PA ” Practice Location

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