Provider Demographics
NPI:1114635174
Name:WOUND COMPANY PROVIDER GROUP, INC.
Entity Type:Organization
Organization Name:WOUND COMPANY PROVIDER GROUP, INC.
Other - Org Name:SANFORD E ROBERTS III MD, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANTLEY
Authorized Official - Middle Name:TILMAN
Authorized Official - Last Name:JOLLY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:703-447-6897
Mailing Address - Street 1:2240 DREW AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-3646
Mailing Address - Country:US
Mailing Address - Phone:858-774-6305
Mailing Address - Fax:
Practice Address - Street 1:2240 DREW AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-3646
Practice Address - Country:US
Practice Address - Phone:858-774-6305
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-09
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WW0000XNursing Service ProvidersRegistered NurseWound CareGroup - Multi-Specialty
No163WC2100XNursing Service ProvidersRegistered NurseContinence CareGroup - Multi-Specialty
No163WE0900XNursing Service ProvidersRegistered NurseEnterostomal TherapyGroup - Multi-Specialty