Provider Demographics
NPI:1558328765
Name:WILSON, STANLEY M (MD)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:M
Last Name:WILSON
Suffix:
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:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:125 DOUGHTY ST
Practice Address - Street 2:SUITE 660
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29403-5736
Practice Address - Country:US
Practice Address - Phone:843-577-7550
Practice Address - Fax:843-853-5588
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11046174400000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC110463Medicaid
SCP00739561OtherRAILROAD MEDICARE ID-RSFPN
SCP00775515OtherRAILROAD MEDICARE ID-AFTER 5/1/2009
SC1374Medicare ID - Type Unspecified
SCD992659223Medicare PIN
SCP00739561OtherRAILROAD MEDICARE ID-RSFPN
SC110463Medicaid