Provider Demographics
NPI:1942269253
Name:WILSON, TIMOTHY M (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:M
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:PO BOX 3380
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29151
Mailing Address - Country:US
Mailing Address - Phone:803-436-5582
Mailing Address - Fax:803-436-0085
Practice Address - Street 1:129 N. WASHINGTON ST.
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150
Practice Address - Country:US
Practice Address - Phone:803-436-5582
Practice Address - Fax:803-436-0085
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17831207LP2900X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC178319Medicaid
SC178319Medicaid