Healthcare Provider Details

I. General information

NPI: 1295871705
Provider Name (Legal Business Name): WILMINGTON MEDICAL GROUP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 11/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 HWY 17 N
HOLLY RIDGE NC
28445-7828
US

IV. Provider business mailing address

1925A OLEANDER DR
WILMINGTON NC
28403-2334
US

V. Phone/Fax

Practice location:
  • Phone: 910-329-1707
  • Fax: 910-251-7777
Mailing address:
  • Phone: 910-251-8851
  • Fax: 910-251-7777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JAMES HENRY PRIDGEN
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 910-329-1707