Provider Demographics
NPI:1558364109
Name:WILSON, BEN WILLIAM JR (MD)
Entity Type:Individual
Prefix:
First Name:BEN
Middle Name:WILLIAM
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 1:10701 ANDERSON RD
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29642-9309
Mailing Address - Country:US
Mailing Address - Phone:864-295-2500
Mailing Address - Fax:
Practice Address - Street 1:10701 ANDERSON RD
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29642-9309
Practice Address - Country:US
Practice Address - Phone:864-295-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23493207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC234936Medicaid
SC593303026005OtherBCBS
NC5901300Medicaid
SC6674Medicare PIN
SCH783009370Medicare PIN
SCH783009368Medicare PIN
SC234936Medicaid
SC593303026005OtherBCBS
NC5901300Medicaid