Provider Demographics
NPI:1194361923
Name:WILMINGTON FAMILY PRACTICE PLLC
Entity Type:Organization
Organization Name:WILMINGTON FAMILY PRACTICE PLLC
Other - Org Name:WILMINGTON FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-500-6415
Mailing Address - Street 1:201 N FRONT ST STE 102
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-4055
Mailing Address - Country:US
Mailing Address - Phone:910-500-6451
Mailing Address - Fax:910-500-6458
Practice Address - Street 1:201 N FRONT ST STE 102
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-4055
Practice Address - Country:US
Practice Address - Phone:910-500-6451
Practice Address - Fax:910-500-6458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-27
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1669918223OtherNPI
NC1992351910Medicaid
NC1821295668Medicaid