Healthcare Provider Details

I. General information

NPI: 1285894352
Provider Name (Legal Business Name): JEREMIAH J WILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2008
Last Update Date: 01/30/2024
Certification Date: 01/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 TELFAIR ST
AUGUSTA GA
30901-2590
US

IV. Provider business mailing address

PO BOX 2344
AUGUSTA GA
30903-2344
US

V. Phone/Fax

Practice location:
  • Phone: 706-922-0600
  • Fax: 706-922-0604
Mailing address:
  • Phone: 706-922-0600
  • Fax: 706-922-0604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number066105
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD30978
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: