=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831363688
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | S. TERRY WITHERS, JR., M.D.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2008
-----------------------------------------------------
Last Update Date | 11/15/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5058 WRIGHTSVILLE AVE
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28403-7048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-791-5426
-----------------------------------------------------
Fax | 910-799-2433
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 598
-----------------------------------------------------
City | WRIGHTSVILLE BEACH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28480-0598
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-791-5426
-----------------------------------------------------
Fax | 910-799-2433
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. S. TERRY WITHERS JR.
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 910-791-5426
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------