Healthcare Provider Details

I. General information

NPI: 1639365562
Provider Name (Legal Business Name): WILMINGTON HEALTH PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2007
Last Update Date: 03/15/2023
Certification Date: 03/15/2023
Deactivation Date: 02/03/2023
Reactivation Date: 03/15/2023

III. Provider practice location address

2421 SILVER STREAM LANE
WILMINGTON NC
28401
US

IV. Provider business mailing address

1202 MEDICAL CENTER DR
WILMINGTON NC
28401-7307
US

V. Phone/Fax

Practice location:
  • Phone: 910-763-2072
  • Fax: 910-763-1586
Mailing address:
  • Phone: 910-763-2072
  • Fax: 910-763-1586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberNC73991
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier89022IL
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: CHASITY CHACE
Title or Position: DIRECTOR BUSINESS SERVICES
Credential:
Phone: 910-341-3384