Provider Demographics
NPI:1275702607
Name:SALLY WILSON MD PLLC
Entity Type:Organization
Organization Name:SALLY WILSON MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:K
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-543-5325
Mailing Address - Street 1:121 S COCHRAN AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:CHARLOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48813-1568
Mailing Address - Country:US
Mailing Address - Phone:517-543-9095
Mailing Address - Fax:517-543-3339
Practice Address - Street 1:121 S COCHRAN AVE
Practice Address - Street 2:SUITE C
Practice Address - City:CHARLOTTE
Practice Address - State:MI
Practice Address - Zip Code:48813-1568
Practice Address - Country:US
Practice Address - Phone:517-543-9095
Practice Address - Fax:517-543-3339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-29
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301068222207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty