Provider Demographics
NPI:1528167608
Name:WBD
Entity type:Organization
Organization Name:WBD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:C
Authorized Official - Last Name:WADE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:601-849-7240
Mailing Address - Street 1:360 SIMPSON HIGHWAY 149 STE 370
Mailing Address - Street 2:
Mailing Address - City:MAGEE
Mailing Address - State:MS
Mailing Address - Zip Code:39111-3843
Mailing Address - Country:US
Mailing Address - Phone:601-849-7240
Mailing Address - Fax:601-849-7244
Practice Address - Street 1:376A SIMPSON HIGHWAY 149
Practice Address - Street 2:
Practice Address - City:MAGEE
Practice Address - State:MS
Practice Address - Zip Code:39111-3409
Practice Address - Country:US
Practice Address - Phone:601-849-7240
Practice Address - Fax:601-849-7244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10798207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09883351Medicaid
MSC48365Medicare UPIN
MSC03316Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER