MEDICARE: DR. LARRY T 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	MD35689	TN
2	207Q00000X	Family Medicine Physician	0101231693	VA
3	207Q00000X	Family Medicine Physician	TL32077	SC

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

General Provider Information

NPI Number	:	1134121221
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARRY T WILSON MD

Provider Business Mailing Address
First Line	:	1075 N FRASER ST
Second Line	:
City	:	GEORGETOWN
State	:	SC
Zip	:	29440
Country	:	US
Telephone Number	:	843-527-4442
Fax Number	:	843-527-4027

Provider Business Practice Location Address
First Line	:	701 S MORGAN AVE
Second Line	:
City	:	ANDREWS
State	:	SC
Zip	:	29510
Country	:	US
Telephone Number	:	843-264-5253
Fax Number	:	843-264-5970

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

Provider Enumeration Date	:	06/02/2005
Last Update Date	:	08/28/2009

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