Provider Demographics
NPI:1619996121
Name:WILSON, SUZANNE L (MD)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 PAGE ROAD
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-8798
Mailing Address - Country:US
Mailing Address - Phone:910-295-5511
Mailing Address - Fax:910-295-5481
Practice Address - Street 1:205 PAGE ROAD
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8798
Practice Address - Country:US
Practice Address - Phone:910-295-5511
Practice Address - Fax:910-295-5481
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2008-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC01975208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN01975OtherSC MEDICAID
NC144NOOtherBCBS
NC5905677Medicaid
NC0407048OtherEVERCARE PROVIDER #
NC195533OtherMEDCOST
NCFH1100235OtherFIRSTCAROLINA
SCN01975OtherSC MEDICAID
NC5905677Medicaid
NCP00414507Medicare PIN