Provider Demographics
NPI:1831363688
Name:S. TERRY WITHERS, JR., M.D.
Entity type:Organization
Organization Name:S. TERRY WITHERS, JR., M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:S.
Authorized Official - Middle Name:TERRY
Authorized Official - Last Name:WITHERS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:910-791-5426
Mailing Address - Street 1:PO BOX 598
Mailing Address - Street 2:
Mailing Address - City:WRIGHTSVILLE BEACH
Mailing Address - State:NC
Mailing Address - Zip Code:28480-0598
Mailing Address - Country:US
Mailing Address - Phone:910-791-5426
Mailing Address - Fax:910-799-2433
Practice Address - Street 1:5058 WRIGHTSVILLE AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-7048
Practice Address - Country:US
Practice Address - Phone:910-791-5426
Practice Address - Fax:910-799-2433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-14
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902268Medicaid
1356532659OtherNPI
1639240617OtherNPI
1356532659OtherNPI
1639240617OtherNPI
NC201718EMedicare PIN