Provider Demographics
NPI:1689682213
Name:WILSON, WILLIAM E (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
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 1:2880 TRICOM ST
Mailing Address - Street 2:
Mailing Address - City:N CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9171
Mailing Address - Country:US
Mailing Address - Phone:843-797-5050
Mailing Address - Fax:843-797-3633
Practice Address - Street 1:2880 TRICOM ST
Practice Address - Street 2:
Practice Address - City:N CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9171
Practice Address - Country:US
Practice Address - Phone:843-797-5050
Practice Address - Fax:843-797-3633
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18102207XX0005X, 207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT19334Medicaid
0253030001OtherDMERC
SC30085651OtherSELECT HEALTH PROVIDER NO.
SCT19334Medicaid
SC57-0634057OtherTAX ID #
0253030001OtherDMERC
G03806Medicare UPIN