=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235218546
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILMINGTON WELLNESS GROUP, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1213 CULBRETH DR
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28405-3684
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-471-4773
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1213 CULBRETH DR
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28405-3684
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-471-4773
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. SHAWN ELLINGTON MCCANN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 910-471-4774
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------