MEDICARE: MICHELLE LERMOND WILSON DO

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	207R00000X	Internal Medicine Physician	39698	GA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00422522	OTHER	GA	RAILROAD MEDICARE PIN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	52576493	OTHER	GA	BCBS

General Provider Information

NPI Number	:	1932129822
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE LERMOND WILSON DO

Provider Business Mailing Address
First Line	:	1000 TOWNE CENTER BLVD BLDG 1200
Second Line	:
City	:	POOLER
State	:	GA
Zip	:	31322-4129
Country	:	US
Telephone Number	:	912-748-2280
Fax Number	:	912-748-4988

Provider Business Practice Location Address
First Line	:	1000 TOWNE CENTER BLVD BLDG 1200
Second Line	:
City	:	POOLER
State	:	GA
Zip	:	31322-4129
Country	:	US
Telephone Number	:	912-748-2280
Fax Number	:	912-748-4988

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

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	02/01/2024

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Directions to “ MICHELLE LERMOND WILSON DO” Practice Location

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