MEDICARE: DR. ERIC WILSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	030694	GA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
5	080184143	OTHER	GA	MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	481143	OTHER	GA	BCBS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	4491297	OTHER	GA	AETNA

General Provider Information

NPI Number	:	1063526507
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ERIC WILSON MD

Provider Business Mailing Address
First Line	:	3495 PIEDMONT RD NE
Second Line	:	NINE PIEDMONT CENTER
City	:	ATLANTA
State	:	GA
Zip	:	30305-1717
Country	:	US
Telephone Number	:	404-364-7070
Fax Number	:	706-549-5981

Provider Business Practice Location Address
First Line	:	5440 HILLANDALE DR
Second Line	:	KAISER PERMANENTE PANOLA MEDICAL CENTER
City	:	LITHONIA
State	:	GA
Zip	:	30058-4865
Country	:	US
Telephone Number	:	770-322-2777
Fax Number	:	706-549-5981

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2006
Last Update Date	:	01/10/2022

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Directions to “ DR. ERIC WILSON MD” Practice Location

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