Basic Information
| Provider Information | |||||||||
| NPI: | 1902896004 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILEY | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2560 OLD SHELL RD | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366073022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2513788635 | ||||||||
| FaxNumber: | 2513788636 | ||||||||
| Practice Location | |||||||||
| Address1: | 2560 OLD SHELL RD | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366073022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2513788635 | ||||||||
| FaxNumber: | 2513788636 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 12/10/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 14295 | AL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 000087291 | 05 | AL | MEDICAID |