Basic Information
| Provider Information | |||||||||
| NPI: | 1992708747 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILMINGTON ANESTHESIOLOGISTS PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3686 | ||||||||
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| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284060686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104421100 | ||||||||
| FaxNumber: | 9104421199 | ||||||||
| Practice Location | |||||||||
| Address1: | 2131 S 17TH ST | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284017407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104421100 | ||||||||
| FaxNumber: | 9104421199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HAHN | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE COMMITTEE CHAIRMAN | ||||||||
| AuthorizedOfficialTelephone: | 9104421100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 1234 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 8902117 | 05 | NC | MEDICAID |