Provider Demographics
NPI:1235255266
Name:WILSON, MICHELLE MARGARITA (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARGARITA
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 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:200 PATEWOOD DR STE C100
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-6322
Practice Address - Country:US
Practice Address - Phone:864-454-7422
Practice Address - Fax:864-454-8265
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27103207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC271039Medicaid
SCP00801509OtherRR MEDICARE
SCP00801509OtherRR MEDICARE
SC271039Medicaid
SC576007863189OtherBCBS OF SC