Provider Demographics
NPI:1528112802
Name:WILSON SURGICAL ASSOCIATES PA
Entity type:Organization
Organization Name:WILSON SURGICAL ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER/VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:BOYD
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:252-399-7557
Mailing Address - Street 1:130 GLENDALE DRIVE WEST
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-2770
Mailing Address - Country:US
Mailing Address - Phone:252-399-7557
Mailing Address - Fax:252-399-1324
Practice Address - Street 1:130 GLENDALE DRIVE WEST
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-2770
Practice Address - Country:US
Practice Address - Phone:252-399-7557
Practice Address - Fax:252-399-1324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5917371Medicaid
2331469Medicare PIN
NC5917371Medicaid