Provider Demographics
NPI:1346218211
Name:VAN DAM, WILSON ALARIC (MD)
Entity Type:Individual
Prefix:DR
First Name:WILSON
Middle Name:ALARIC
Last Name:VAN DAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 22265
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4473
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:14 RICHLAND MEDICAL PARK DR
Practice Address - Street 2:SUITE 200
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6877
Practice Address - Country:US
Practice Address - Phone:803-296-9200
Practice Address - Fax:803-296-9697
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCT6565208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC224260Medicaid
SCG87822Medicare UPIN
SCSC6171E878Medicare PIN
SCG87822Medicare UPIN