1881890614 NPI number — D BRUCE WILSON MD, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881890614 NPI number — D BRUCE WILSON MD, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
D BRUCE 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:
1881890614
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
188 S BELLEVUE BLVD
Provider Second Line Business Mailing Address:
#405
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38104-3416
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-725-4400
Provider Business Mailing Address Fax Number:
901-516-8996

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
188 S BELLEVUE BLVD
Provider Second Line Business Practice Location Address:
#405
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38104-3416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-725-4400
Provider Business Practice Location Address Fax Number:
901-516-8996
Provider Enumeration Date:
06/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WILSON
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
BRUCE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
901-725-4400

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  MD009123 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 120197 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 13799 . This is a "BLUE CROSSBLUE SHIELD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3388 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 511754 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00126945 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4724230 . This is a "CIGN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 89359 . This is a "BLUE CROSS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 3386286 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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