Provider Demographics
NPI:1366262545
Name:WJG MULTISPECIALTY CLINIC PC
Entity type:Organization
Organization Name:WJG MULTISPECIALTY CLINIC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WOODRUFF
Authorized Official - Middle Name:HALL
Authorized Official - Last Name:BAUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-568-0193
Mailing Address - Street 1:PO BOX 53302
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85072-3302
Mailing Address - Country:US
Mailing Address - Phone:844-509-1404
Mailing Address - Fax:844-278-8635
Practice Address - Street 1:625 BROADWAY STE 625A
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3375
Practice Address - Country:US
Practice Address - Phone:207-605-5593
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-14
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy