Provider Demographics
NPI:1487627394
Name:WILSON, FRED PALMER JR (MD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:PALMER
Last Name:WILSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7140 STAGE RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38133-8955
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7140 STAGE RD
Practice Address - Street 2:SUITE 106
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38133-8955
Practice Address - Country:US
Practice Address - Phone:901-377-6120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN21882207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3064418Medicaid
TNF08258Medicare UPIN
TN3064418Medicaid