Provider Demographics
NPI:1932129822
Name:WILSON, MICHELLE LERMOND (DO)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LERMOND
Last Name:WILSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 TOWNE CENTER BLVD BLDG 1200
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-4129
Mailing Address - Country:US
Mailing Address - Phone:912-748-2280
Mailing Address - Fax:912-748-4988
Practice Address - Street 1:1000 TOWNE CENTER BLVD BLDG 1200
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-4129
Practice Address - Country:US
Practice Address - Phone:912-748-2280
Practice Address - Fax:912-748-4988
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA39698207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52576493OtherBCBS
GAP00422522OtherRAILROAD MEDICARE PIN
GAG14976Medicare UPIN
GA52576493OtherBCBS