Provider Demographics
NPI:1881819407
Name:WILMINGTON PRIMARY CARE, PA
Entity Type:Organization
Organization Name:WILMINGTON PRIMARY CARE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FRED
Authorized Official - Middle Name:H
Authorized Official - Last Name:VAN NYNATTEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-762-7071
Mailing Address - Street 1:1990 S 16TH ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-6647
Mailing Address - Country:US
Mailing Address - Phone:910-762-7071
Mailing Address - Fax:910-762-9658
Practice Address - Street 1:1990 S 16TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6647
Practice Address - Country:US
Practice Address - Phone:910-762-7071
Practice Address - Fax:910-762-9658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19777207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC80931Medicare UPIN