Provider Demographics
NPI:1669473237
Name:WILSON, BRIAN CLAUD (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:CLAUD
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 1:197 S HERLONG AVE
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-3427
Mailing Address - Country:US
Mailing Address - Phone:803-366-9000
Mailing Address - Fax:803-366-9200
Practice Address - Street 1:197 S HERLONG AVE
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-3427
Practice Address - Country:US
Practice Address - Phone:803-366-9000
Practice Address - Fax:803-366-9200
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15101207Y00000X
NC39899207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC151016Medicaid
SCQ268558926Medicare PIN
SCE20882Medicare UPIN