Provider Demographics
NPI:1932401411
Name:WILMINGTON PHYSICIANS GROUP LLC
Entity Type:Organization
Organization Name:WILMINGTON PHYSICIANS GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:TEAGUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-920-7000
Mailing Address - Street 1:610 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177-2125
Mailing Address - Country:US
Mailing Address - Phone:937-283-9845
Mailing Address - Fax:937-283-9839
Practice Address - Street 1:610 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-2125
Practice Address - Country:US
Practice Address - Phone:937-382-5438
Practice Address - Fax:937-382-5260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-03
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0050274Medicaid
OH0050274Medicaid