Provider Demographics
NPI:1942293717
Name:WILSON NEPHROLOGY-INTERNAL MEDICINE PA
Entity Type:Organization
Organization Name:WILSON NEPHROLOGY-INTERNAL MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANWAR
Authorized Official - Middle Name:D
Authorized Official - Last Name:AL-HAIDARY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-243-2268
Mailing Address - Street 1:PO BOX 3127
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27895-3127
Mailing Address - Country:US
Mailing Address - Phone:252-243-2268
Mailing Address - Fax:252-243-2917
Practice Address - Street 1:2503 WOOTEN BLVD
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893
Practice Address - Country:US
Practice Address - Phone:252-243-2268
Practice Address - Fax:252-243-2917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0140NOtherBLUE CROSS BLUE SHIELD
NC890140NMedicaid
NC0140NOtherBLUE CROSS BLUE SHIELD