Provider Demographics
NPI:1861245169
Name:WISE, JAMES BENJAMIN STALLWORTH (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:BENJAMIN STALLWORTH
Last Name:WISE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CONE HEALTH BEHAVIORAL HEALTH
Mailing Address - Street 2:931 THIRD STREET - 2ND FLOOR RESIDENCY
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405
Mailing Address - Country:US
Mailing Address - Phone:336-832-9626
Mailing Address - Fax:
Practice Address - Street 1:CONE HEALTH BEHAVIORAL HEALTH HOSPITAL
Practice Address - Street 2:700 WALTER REED DRIVE
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27403
Practice Address - Country:US
Practice Address - Phone:336-832-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC20727305OtherNC DRIVER'S LICENSE