=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164775037
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JIMMIE JEAN WILBUR MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2012
-----------------------------------------------------
Last Update Date | 11/28/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13381 N. 56TH ST.
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-984-9700
-----------------------------------------------------
Fax | 813-984-2889
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13381 N. 56TH ST.
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-984-9700
-----------------------------------------------------
Fax | 813-984-2889
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | JIMMIE J WILBUR
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 813-984-9700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME0067395
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------