Basic Information
| Provider Information | |||||||||
| NPI: | 1649667577 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILMER MEDICAL CLINIC, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10075 GRAND BAY WILMER RD S | ||||||||
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| City: | GRAND BAY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 365415003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2518651852 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6353 2ND STREET | ||||||||
| Address2: | |||||||||
| City: | WILMER | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36587 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2518651852 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2015 | ||||||||
| LastUpdateDate: | 10/26/2015 | ||||||||
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| AuthorizedOfficialLastName: | STOKES | ||||||||
| AuthorizedOfficialFirstName: | LLOYD | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 2518651852 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | NP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.