Healthcare Provider Details

I. General information

NPI: 1467646471
Provider Name (Legal Business Name): BENJAMIN SCOTT WILES D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2007
Last Update Date: 12/23/2021
Certification Date: 12/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2131 S 17TH ST
WILMINGTON NC
28401-7407
US

IV. Provider business mailing address

4402 SHIPYARD BLVD
WILMINGTON NC
28403-6161
US

V. Phone/Fax

Practice location:
  • Phone: 910-667-7000
  • Fax:
Mailing address:
  • Phone: 910-202-3363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number200901484
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2337
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: