=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366262545
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WJG MULTISPECIALTY CLINIC PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2024
-----------------------------------------------------
Last Update Date | 01/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 625 BROADWAY STE 625A
-----------------------------------------------------
City | BANGOR
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04401-3375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-605-5593
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 53302
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85072-3302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-509-1404
-----------------------------------------------------
Fax | 844-278-8635
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | WOODRUFF HALL BAUM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 646-568-0193
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------