Provider Demographics
NPI:1285942557
Name:ERIC WILSON MD PC
Entity type:Organization
Organization Name:ERIC WILSON MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-549-5832
Mailing Address - Street 1:PO BOX 7848
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30604-7848
Mailing Address - Country:US
Mailing Address - Phone:706-549-5832
Mailing Address - Fax:706-549-5981
Practice Address - Street 1:700 SUNSET DR
Practice Address - Street 2:BUILDING 400
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2293
Practice Address - Country:US
Practice Address - Phone:706-549-5832
Practice Address - Fax:706-549-5981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-20
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAE19881Medicare UPIN
GA08BDCGGMedicare PIN