1174529036 NPI number — CHARLES E. WILSON, MD, PC

Table of content: (NPI 1174529036)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174529036 NPI number — CHARLES E. WILSON, MD, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHARLES E. WILSON, MD, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174529036
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
541 W COLLEGE ST
Provider Second Line Business Mailing Address:
STE 3500
Provider Business Mailing Address City Name:
FLORENCE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35630-5326
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-718-2188
Provider Business Mailing Address Fax Number:
256-718-3363

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
541 W COLLEGE ST
Provider Second Line Business Practice Location Address:
STE 3500
Provider Business Practice Location Address City Name:
FLORENCE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35630-5326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-718-2188
Provider Business Practice Location Address Fax Number:
256-718-3363
Provider Enumeration Date:
06/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WILSON
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
ELMO
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
256-718-2188

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  6987 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208800000X , with the licence number: 15126 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1416173 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 529912610 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4042085 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4661630001 . This is a "PALMETTO DMERC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 09016248 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: DN0441 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 51509142 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: DH0160 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 09016288 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4046425 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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