Provider Demographics
NPI:1073653739
Name:WILSON C SY MD PA
Entity Type:Organization
Organization Name:WILSON C SY MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WILSON
Authorized Official - Middle Name:C
Authorized Official - Last Name:SY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:956-631-2529
Mailing Address - Street 1:5111 N 10TH ST # 347
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78504-2835
Mailing Address - Country:US
Mailing Address - Phone:956-631-2529
Mailing Address - Fax:956-631-2933
Practice Address - Street 1:1102 W TRENTON RD
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-9105
Practice Address - Country:US
Practice Address - Phone:956-631-2529
Practice Address - Fax:956-631-2933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2023-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1085174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX117103OtherCHIPS
TX110661901Medicaid
TX00530DOtherBLUE CROSS BLUE SHIELD TX
TX110661902OtherMEDICAID CSHCN NUMBER
TX117103OtherCHIPS
TX110661901Medicaid