Healthcare Provider Details

I. General information

NPI: 1083619332
Provider Name (Legal Business Name): WILEY HUGH JUSTICE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 06/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5721 USA NORTH DR HAHN 1119
MOBILE AL
36688-0002
US

IV. Provider business mailing address

PO BOX 40277
MOBILE AL
36688-0277
US

V. Phone/Fax

Practice location:
  • Phone: 251-445-9378
  • Fax: 251-445-9377
Mailing address:
  • Phone: 251-445-9378
  • Fax: 251-445-9377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number00007930
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: