Provider Demographics
NPI:1982680419
Name:WILSON, GEORGE ANDREW JR (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:ANDREW
Last Name:WILSON
Suffix:JR
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 1:1530 N 7TH ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47807-1057
Mailing Address - Country:US
Mailing Address - Phone:812-238-4900
Mailing Address - Fax:812-238-4921
Practice Address - Street 1:1530 N 7TH ST
Practice Address - Street 2:SUITE 107
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-1057
Practice Address - Country:US
Practice Address - Phone:812-238-4900
Practice Address - Fax:812-238-4921
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057579A174400000X, 207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000295844OtherBLUE CROSS
IN200452000AMedicaid
IN000000295844OtherUFCW
IN000000295844OtherUNOO
INP00058804OtherPALM
INICHIAOtherICHIA
IN000000295844OtherBLUE CROSS
INICHIAOtherICHIA
IN000000295844OtherUNOO