Provider Demographics
NPI:1639284300
Name:WILSON, WILLIAM L (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:L
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 1:85 HERRICK ST
Mailing Address - Street 2:LAHEY AT BEVERLY HOSPITAL
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-1790
Mailing Address - Country:US
Mailing Address - Phone:978-922-3000
Mailing Address - Fax:978-921-7048
Practice Address - Street 1:85 HERRICK ST
Practice Address - Street 2:LAHEY AT BEVERLY HOSPITAL
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-1790
Practice Address - Country:US
Practice Address - Phone:978-922-3000
Practice Address - Fax:978-921-7048
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN22648207Q00000X
MA238644261QC1500X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ47582OtherBCBS
MN55A04WIOtherBCBS
MA110086079AMedicaid
MN755590300Medicaid
MND80234Medicare UPIN
MN755590300Medicaid
MA0016982Medicare PIN
MN080116270Medicare PIN