Provider Demographics
NPI:1174529036
Name:CHARLES E. WILSON, MD, PC
Entity type:Organization
Organization Name:CHARLES E. WILSON, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:ELMO
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-718-2188
Mailing Address - Street 1:541 W COLLEGE ST
Mailing Address - Street 2:STE 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:STE 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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-24
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15126208800000X
AL6987208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1416173OtherHIGHMARK BLUE SHIELD
AL529912610Medicaid
TN4042085OtherBLUE CROSS BLUE SHIELD
4661630001OtherPALMETTO DMERC
MS09016248Medicaid
MSDN0441OtherRAILROAD MEDICARE
AL51509142OtherBLUE CROSS BLUE SHIELD
ALDH0160OtherRAILROAD MEDICARE
MS09016288Medicaid
TN4046425Medicaid
PA1416173OtherHIGHMARK BLUE SHIELD
MSDN0441OtherRAILROAD MEDICARE
AL529912610Medicaid