Provider Demographics
NPI:1457497968
Name:WILMINGTON MEDICAL GROUP PA
Entity Type:Organization
Organization Name:WILMINGTON MEDICAL GROUP PA
Other - Org Name:NORTHSIDE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:PRIDGEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-251-7715
Mailing Address - Street 1:1925A OLEANDER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-2334
Mailing Address - Country:US
Mailing Address - Phone:910-251-7715
Mailing Address - Fax:910-251-7777
Practice Address - Street 1:1925A OLEANDER DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-2334
Practice Address - Country:US
Practice Address - Phone:910-251-7715
Practice Address - Fax:910-251-7777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89012R9Medicaid
NC230038OtherMEDICARE
NC012R9OtherBCBS