Basic Information
| Provider Information | |||||||||
| NPI: | 1609868942 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 S FRONT ST | ||||||||
| Address2: | |||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171012010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172318772 | ||||||||
| FaxNumber: | 7172318435 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 S FRONT ST | ||||||||
| Address2: | |||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 17101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172318772 | ||||||||
| FaxNumber: | 7172318435 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2005 | ||||||||
| LastUpdateDate: | 01/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 01/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 038133 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | ME104749 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD051413L | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0006565876G | 05 | GA | MEDICAID | 1189235 | 01 | GA | FIRST HEALTH | OTHER | 103115186 | 05 | PA | MEDICAID | 110235293 | 01 | GA | RAILROAD MEDICARE | OTHER | 914260600 | 05 | FL | MEDICAID | 52484977 | 01 | GA | BCBS GA | OTHER |