Provider Demographics
NPI:1588601421
Name:WILSON FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:WILSON FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSSINESS OWNER/MD
Authorized Official - Prefix:DR
Authorized Official - First Name:VICARI
Authorized Official - Middle Name:SUSAN
Authorized Official - Last Name:ERWIN-WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-219-2273
Mailing Address - Street 1:2621 MITCHAM DRIVE
Mailing Address - Street 2:UNIT 103
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5307
Mailing Address - Country:US
Mailing Address - Phone:850-219-2273
Mailing Address - Fax:850-201-2410
Practice Address - Street 1:2621 MITCHAM DR
Practice Address - Street 2:UNIT 103
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5480
Practice Address - Country:US
Practice Address - Phone:850-219-2273
Practice Address - Fax:850-201-2410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL800017593207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherTAXID#
FL=========OtherTAXID#
FLE822598Medicare UPIN
FLE62245Medicare UPIN