Provider Demographics
NPI:1871558262
Name:INTERNAL MEDICINE & WELLNESS CENTER PA
Entity type:Organization
Organization Name:INTERNAL MEDICINE & WELLNESS CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:WOODWARD
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:704-503-6321
Mailing Address - Street 1:10320 MALLARD CREEK RD STE 271
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-5204
Mailing Address - Country:US
Mailing Address - Phone:045-036-3217
Mailing Address - Fax:704-503-7957
Practice Address - Street 1:10320 MALLARD CREEK RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-9756
Practice Address - Country:US
Practice Address - Phone:704-503-1332
Practice Address - Fax:704-503-7951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-19
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical GeneticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1508072620Medicaid
NC6811OtherBCBS ID