Provider Demographics
NPI:1073529053
Name:WILSON, MALISSA GAIL (MD)
Entity Type:Individual
Prefix:DR
First Name:MALISSA
Middle Name:GAIL
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:MALISSA
Other - Middle Name:GAIL
Other - Last Name:KINARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15 RICHLAND MEDICAL PARK
Mailing Address - Street 2:PALMETTO SENIOR CARE STE 203
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203
Mailing Address - Country:US
Mailing Address - Phone:803-434-3770
Mailing Address - Fax:803-434-3773
Practice Address - Street 1:1308 LAUREL STREET
Practice Address - Street 2:PALMETTO SENIOR CARE LAUREL
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201
Practice Address - Country:US
Practice Address - Phone:803-931-8166
Practice Address - Fax:803-931-8183
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14482207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F46855Medicare UPIN