Provider Demographics
NPI:1568455541
Name:WILSON, MICHAEL E (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
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 219
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRING
Mailing Address - State:GA
Mailing Address - Zip Code:30739-0219
Mailing Address - Country:US
Mailing Address - Phone:706-375-3520
Mailing Address - Fax:706-375-9310
Practice Address - Street 1:8566C N HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:ROCK SPRING
Practice Address - State:GA
Practice Address - Zip Code:30739-2105
Practice Address - Country:US
Practice Address - Phone:706-375-3520
Practice Address - Fax:706-375-9310
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032496207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN146966OtherBCBS OF TENNESSEE
GA293865OtherBCBS OF GEORGIA
GA00508802BMedicaid
GA11BDMPWMedicare ID - Type Unspecified
GAE91370Medicare UPIN