Basic Information
| Provider Information | |||||||||
| NPI: | 1003821547 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WILMINGTON SURGICAL ASSOCIATES PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1414 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284017505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107637363 | ||||||||
| FaxNumber: | 9102518296 | ||||||||
| Practice Location | |||||||||
| Address1: | 1414 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284017505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107637363 | ||||||||
| FaxNumber: | 9102518296 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 01/10/2017 | ||||||||
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| AuthorizedOfficialLastName: | HOBBS | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9107637363 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 890260G | 05 | NC | MEDICAID |