Provider Demographics
NPI:1558628701
Name:JERRY MARK WIGLEY MD
Entity Type:Organization
Organization Name:JERRY MARK WIGLEY MD
Other - Org Name:WALK-IN MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:M.D./OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:WIGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-387-4544
Mailing Address - Street 1:179 PINE GROVE RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-8422
Mailing Address - Country:US
Mailing Address - Phone:770-387-4544
Mailing Address - Fax:
Practice Address - Street 1:179 PINE GROVE RD
Practice Address - Street 2:SUITE B
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-8422
Practice Address - Country:US
Practice Address - Phone:770-387-4544
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-12
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034078207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty