Healthcare Provider Details

I. General information

NPI: 1215998067
Provider Name (Legal Business Name): GLEN MEADE OB-GYN PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 08/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1809 GLEN MEADE RD
WILMINGTON NC
28403
US

IV. Provider business mailing address

1809 GLEN MEADE RD
WILMINGTON NC
28403
US

V. Phone/Fax

Practice location:
  • Phone: 910-763-9833
  • Fax:
Mailing address:
  • Phone: 910-763-9833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CLARENCE L WILSON II
Title or Position: VICE-PRES
Credential: MD
Phone: 910-763-9833