MEDICARE: WILMINGTON MEDICAL GROUP PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	230038	OTHER	NC	MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	012R8	OTHER	NC	BCBS

General Provider Information

NPI Number	:	1295871705
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILMINGTON MEDICAL GROUP PA

Provider Business Mailing Address
First Line	:	1925A OLEANDER DR
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28403-2334
Country	:	US
Telephone Number	:	910-251-8851
Fax Number	:	910-251-7777

Provider Business Practice Location Address
First Line	:	308 HWY 17 N
Second Line	:
City	:	HOLLY RIDGE
State	:	NC
Zip	:	28445-7828
Country	:	US
Telephone Number	:	910-329-1707
Fax Number	:	910-251-7777

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	JAMES HENRY PRIDGEN
Credential	:	M.D.
Telephone Number	:	910-329-1707

Provider Enumeration Date	:	01/30/2007
Last Update Date	:	11/20/2007

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Directions to “WILMINGTON MEDICAL GROUP PA ” Practice Location

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