Basic Information
| Provider Information | |||||||||
| NPI: | 1619924891 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALDRICH | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1202 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284017307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103413300 | ||||||||
| FaxNumber: | 9108152882 | ||||||||
| Practice Location | |||||||||
| Address1: | 904 N HOWE ST | ||||||||
| Address2: | |||||||||
| City: | SOUTHPORT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284613038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103413300 | ||||||||
| FaxNumber: | 9108152882 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 10/23/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 9600838 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207R00000X | 9600838 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 891030K | 05 | NC | MEDICAID |