Provider Demographics
NPI:1619974672
Name:WILSON, SCOTT A (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:A
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 27
Mailing Address - Street 2:
Mailing Address - City:MANVILLE
Mailing Address - State:RI
Mailing Address - Zip Code:02838-0027
Mailing Address - Country:US
Mailing Address - Phone:800-927-0002
Mailing Address - Fax:603-890-1236
Practice Address - Street 1:106 NATE WHIPPLE HWY
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:RI
Practice Address - Zip Code:02864-1403
Practice Address - Country:US
Practice Address - Phone:401-658-2020
Practice Address - Fax:401-658-3612
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD10225207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7008327Medicaid
RIH17215Medicare UPIN
RI007008327Medicare ID - Type Unspecified