Provider Demographics
NPI:1124068432
Name:WILSON, RUSSELL CHAPMAN (MD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:CHAPMAN
Last Name:WILSON
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:PO BOX 19368
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27619-9368
Mailing Address - Country:US
Mailing Address - Phone:919-787-8221
Mailing Address - Fax:919-789-4461
Practice Address - Street 1:3949 BROWNING PL
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6504
Practice Address - Country:US
Practice Address - Phone:919-787-8221
Practice Address - Fax:919-789-4461
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCD9130OtherMEDCOST
NCD9131OtherMEDCOST
NC2500018OtherUNITED HEALTHCARE
NC6297819OtherCIGNA
NC138KFOtherBLUECROSS BLUESHIELD
NCP00263266OtherRAILROAD MEDICARE
NCD8898OtherMEDCOST
NCP00258193OtherRAILROAD MEDICARE
NC7146484OtherAETNA
NC89138KFMedicaid
NCP00263266OtherRAILROAD MEDICARE
NC6297819OtherCIGNA
H84040Medicare UPIN
NC2035871AMedicare ID - Type Unspecified