Provider Demographics
NPI:1639201056
Name:WILMINGTON INTERNAL MEDICINE PA
Entity Type:Organization
Organization Name:WILMINGTON INTERNAL MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-762-4600
Mailing Address - Street 1:2215 CANTERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7301
Mailing Address - Country:US
Mailing Address - Phone:910-762-4600
Mailing Address - Fax:910-762-9483
Practice Address - Street 1:2215 CANTERWOOD DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7301
Practice Address - Country:US
Practice Address - Phone:910-762-4600
Practice Address - Fax:910-762-9483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC85716207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7978365Medicaid
NC0176COtherBLUE CROSS PROVIDER #
NC0176COtherBLUE CROSS PROVIDER #
NC2344407Medicare ID - Type UnspecifiedPROVIDER NUMBER