Healthcare Provider Details

I. General information

NPI: 1588399745
Provider Name (Legal Business Name): WJG MULTISPECIALTY CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2022
Last Update Date: 05/09/2025
Certification Date: 05/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

194 PLEASANT ST STE 7
CONCORD NH
03301-2952
US

IV. Provider business mailing address

PO BOX 53302
PHOENIX AZ
85072-3302
US

V. Phone/Fax

Practice location:
  • Phone: 603-208-3085
  • Fax: 603-217-5371
Mailing address:
  • Phone: 844-614-2354
  • Fax: 844-278-8635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CHARLES MICHAEL BUCY
Title or Position: SENIOR REIMBURSEMENT MANAGER
Credential:
Phone: 717-383-0392