Provider Demographics
NPI:1639176951
Name:WILSON, FREDDIE E (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDDIE
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 1:357 WOODRUFF RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-3415
Mailing Address - Country:US
Mailing Address - Phone:864-627-5337
Mailing Address - Fax:864-627-9301
Practice Address - Street 1:357 WOODRUFF RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-3415
Practice Address - Country:US
Practice Address - Phone:864-627-5337
Practice Address - Fax:864-627-9301
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6040207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC060409Medicaid
SC7340Medicare PIN
SC060409Medicaid