Basic Information
| Provider Information | |||||||||
| NPI: | 1962538447 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILSON MEDICAL CENTER, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | POWELL MEMORIAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11180 FINCH AVENUE | ||||||||
| Address2: | P.O. BOX 879 | ||||||||
| City: | MIDDLESEX | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275570879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2522352298 | ||||||||
| FaxNumber: | 2523998829 | ||||||||
| Practice Location | |||||||||
| Address1: | 11180 FINCH AVENUE | ||||||||
| Address2: | |||||||||
| City: | MIDDLESEX | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2522352298 | ||||||||
| FaxNumber: | 2523998829 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2007 | ||||||||
| LastUpdateDate: | 09/07/2007 | ||||||||
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| AuthorizedOfficialLastName: | HUDSON | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2523998139 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WILSON MEDICAL CENTER, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0156L | 01 | NC | NC BC PROVIDER NO. | OTHER | 7901436 | 05 | NC | MEDICAID |