Provider Demographics
NPI:1215996046
Name:WILSON INTERNAL MEDICINE PA
Entity type:Organization
Organization Name:WILSON INTERNAL MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:D
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:M D
Authorized Official - Phone:803-799-0201
Mailing Address - Street 1:4840 FOREST DR
Mailing Address - Street 2:BOX 255
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29206-4810
Mailing Address - Country:US
Mailing Address - Phone:803-799-0201
Mailing Address - Fax:803-799-0304
Practice Address - Street 1:4840 FOREST DR
Practice Address - Street 2:BOX 255
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29206-4810
Practice Address - Country:US
Practice Address - Phone:803-799-0201
Practice Address - Fax:803-799-0304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12953261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCC87729Medicare UPIN
SC8169Medicare PIN