Provider Demographics
NPI:1093719726
Name:WILSON, SUSAN KADY (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:KADY
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 RANDOLPH RD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-1122
Mailing Address - Country:US
Mailing Address - Phone:704-384-9113
Mailing Address - Fax:704-316-0508
Practice Address - Street 1:14 DOCTORS CIR
Practice Address - Street 2:SUITE 5
Practice Address - City:SUPPLY
Practice Address - State:NC
Practice Address - Zip Code:28462-4097
Practice Address - Country:US
Practice Address - Phone:910-754-9166
Practice Address - Fax:910-754-2972
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19107207V00000X
NC207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT30464Medicaid
NCG40086Medicare UPIN