Basic Information
| Provider Information | |||||||||
| NPI: | 1942269253 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3380 | ||||||||
| Address2: | |||||||||
| City: | SUMTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034365582 | ||||||||
| FaxNumber: | 8034360085 | ||||||||
| Practice Location | |||||||||
| Address1: | 129 N. WASHINGTON ST. | ||||||||
| Address2: | |||||||||
| City: | SUMTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034365582 | ||||||||
| FaxNumber: | 8034360085 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 06/14/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 17831 | SC | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | 17831 | SC | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 178319 | 05 | SC | MEDICAID |