Basic Information
| Provider Information | |||||||||
| NPI: | 1295948339 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILMINGTON GASTROENTEROLOGY ENDOSCOPY CENTER, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5115 OLEANDER DRIVE | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284037018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103621011 | ||||||||
| FaxNumber: | 9103621012 | ||||||||
| Practice Location | |||||||||
| Address1: | 5115 OLEANDER DRIVE | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284037018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103621011 | ||||||||
| FaxNumber: | 9103621012 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2007 | ||||||||
| LastUpdateDate: | 01/09/2014 | ||||||||
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| AuthorizedOfficialLastName: | PETERSON | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9103621011 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MBA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | AS0091 | NC | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | AS0091 | 01 | NC | ASC LICENSE NUMBER | OTHER |