Provider Demographics
NPI:1215998067
Name:GLEN MEADE OB-GYN PA
Entity type:Organization
Organization Name:GLEN MEADE OB-GYN PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:910-763-9833
Mailing Address - Street 1:1809 GLEN MEADE RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403
Mailing Address - Country:US
Mailing Address - Phone:910-763-9833
Mailing Address - Fax:
Practice Address - Street 1:1809 GLEN MEADE RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403
Practice Address - Country:US
Practice Address - Phone:910-763-9833
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-31
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2311229Medicare PIN