Provider Demographics
NPI:1598911877
Name:GEORGE E. WILKERSON, M.D., P.A.
Entity Type:Organization
Organization Name:GEORGE E. WILKERSON, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:WILKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-824-4354
Mailing Address - Street 1:348 CROSSGATES BLVD STE 2300
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-2634
Mailing Address - Country:US
Mailing Address - Phone:601-824-4354
Mailing Address - Fax:601-824-6042
Practice Address - Street 1:348 CROSSGATES BLVD STE 2300
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-2634
Practice Address - Country:US
Practice Address - Phone:601-824-4354
Practice Address - Fax:601-824-6042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-18
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS05507261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS130000173OtherMEDICARE ID - TYPE UNSPECIFIED
MS00014453Medicaid
MS1689758385Medicare PIN
MS00014453Medicaid