Provider Demographics
NPI:1922040419
Name:WILMINGTON GASTROENTEROLOGY ASSOCIATES,PA
Entity Type:Organization
Organization Name:WILMINGTON GASTROENTEROLOGY ASSOCIATES,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:910-362-1011
Mailing Address - Street 1:5115 OLEANDER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-7018
Mailing Address - Country:US
Mailing Address - Phone:910-362-1011
Mailing Address - Fax:
Practice Address - Street 1:5115 OLEANDER DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-7018
Practice Address - Country:US
Practice Address - Phone:910-362-1011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2344647Medicare PIN