Basic Information
Provider Information | |||||||||
NPI: | 1578901005 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WILSON MEDICAL CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WORKWELL CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1705 TARBORO ST SW | ||||||||
Address2: |   | ||||||||
City: | WILSON | ||||||||
State: | NC | ||||||||
PostalCode: | 278933428 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2523998040 | ||||||||
FaxNumber: | 2523998778 | ||||||||
Practice Location | |||||||||
Address1: | 1705 TARBORO ST SW | ||||||||
Address2: |   | ||||||||
City: | WILSON | ||||||||
State: | NC | ||||||||
PostalCode: | 278933428 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2523998040 | ||||||||
FaxNumber: | 2523998778 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/06/2013 | ||||||||
LastUpdateDate: | 06/06/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HUDSON | ||||||||
AuthorizedOfficialFirstName: | RICHARD | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
AuthorizedOfficialTelephone: | 2523998139 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083P0500X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Preventive Medicine/Occupational Environmental Medicine |
ID Information
ID | Type | State | Issuer | Description | 3400126 | 05 | NC |   | MEDICAID | 3400126A | 05 | NC |   | MEDICAID |