Provider Demographics
NPI:1750479754
Name:WILSON, GLENN L (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:L
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:G.
Other - Middle Name:LEE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:100 MEDICAL CENTER DR.
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35903-1130
Mailing Address - Country:US
Mailing Address - Phone:256-492-8590
Mailing Address - Fax:256-492-4498
Practice Address - Street 1:100 MEDICAL CENTER DR.
Practice Address - Street 2:SUITE 101
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35903-1130
Practice Address - Country:US
Practice Address - Phone:256-492-8590
Practice Address - Fax:256-492-4498
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD28405207X00000X
NC28405207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL131368Medicaid