Provider Demographics
NPI:1679549885
Name:RUSSELL, WILSON GLOVER (MD)
Entity Type:Individual
Prefix:DR
First Name:WILSON
Middle Name:GLOVER
Last Name:RUSSELL
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 30369
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27130-0369
Mailing Address - Country:US
Mailing Address - Phone:336-718-5856
Mailing Address - Fax:336-718-9259
Practice Address - Street 1:3333 SILAS CREEK PKWY
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3013
Practice Address - Country:US
Practice Address - Phone:336-718-5856
Practice Address - Fax:336-718-9259
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC24810207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC74049OtherBCBS
NC8974049Medicaid
NC74049OtherBCBS
NC8974049Medicaid
NC213496AMedicare PIN
NC213496CMedicare PIN