Basic Information
| Provider Information | |||||||||
| NPI: | 1982961314 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILSON MEDICAL CENTER, INC. | ||||||||
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| OtherOrganizationName: | HOME CARE OF WILSON MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| 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: | 04/23/2012 | ||||||||
| LastUpdateDate: | 05/11/2012 | ||||||||
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| AuthorizedOfficialLastName: | HUDSON | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 2523998139 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WILSON MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3747P1801X | 0067726 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Nursing Service Related Providers | Technician | Personal Care Attendant |
ID Information
| ID | Type | State | Issuer | Description | 6602116 | 05 | NC | MEDICAID |