Provider Demographics
NPI:1336323815
Name:FREDDIE E. WILSON MD
Entity Type:Organization
Organization Name:FREDDIE E. WILSON MD
Other - Org Name:SOUTHEAST REGIONAL SLEEP DISORDERS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATRINKA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SCALISE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-627-5337
Mailing Address - Street 1:357 WOODRUFF RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-3415
Mailing Address - Country:US
Mailing Address - Phone:864-627-5337
Mailing Address - Fax:864-627-9301
Practice Address - Street 1:357 WOODRUFF RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-3415
Practice Address - Country:US
Practice Address - Phone:864-627-5337
Practice Address - Fax:864-627-9301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-20
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6040174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC060409Medicaid
SCD17931Medicare UPIN
SC060409Medicaid
SCP00014125Medicare PIN