Provider Demographics
NPI:1104823202
Name:WILSON, CHARLES E (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:E
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:541 W COLLEGE ST
Mailing Address - Street 2:SUITE 3500
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630-5326
Mailing Address - Country:US
Mailing Address - Phone:256-718-2188
Mailing Address - Fax:256-718-3363
Practice Address - Street 1:541 W COLLEGE ST
Practice Address - Street 2:SUITE 3500
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-5326
Practice Address - Country:US
Practice Address - Phone:256-718-2188
Practice Address - Fax:256-718-3363
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6987208800000X
MS15126208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL340020199OtherRAILROAD MEDICARE
MS340020200OtherRAILROAD MEDICARE
TN4042085OtherBLUE CROSS BLUE SHIELD
AL51509142OtherBLUE CROSS BLUE SHIELD
MS0126868Medicaid
TN4046425Medicaid
4123452OtherAETNA
4661630001OtherPALMETTO DMERC
PA1416173OtherHIGHMARK BLUE SHIELD
AL529912610Medicaid
MS340020200OtherRAILROAD MEDICARE
PA1416173OtherHIGHMARK BLUE SHIELD
MS340000237Medicare PIN