Basic Information
| Provider Information | |||||||||
| NPI: | 1932129822 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | LERMOND | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15849 | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314162549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123033552 | ||||||||
| FaxNumber: | 9123033506 | ||||||||
| Practice Location | |||||||||
| Address1: | 143 CANAL ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | POOLER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313226008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123305143 | ||||||||
| FaxNumber: | 9123305149 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 08/02/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 39698 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00422522 | 01 | GA | RAILROAD MEDICARE PIN | OTHER | 52576493 | 01 | GA | BCBS | OTHER |