Healthcare Provider Details

I. General information

NPI: 1134106925
Provider Name (Legal Business Name): CLAY H WILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 11/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 ST. SEBASTIAN WAY SUITE 8A
AUGUSTA GA
30901
US

IV. Provider business mailing address

820 ST. SEBASTIAN WAY SUITE 8A
AUGUSTA GA
30901
US

V. Phone/Fax

Practice location:
  • Phone: 706-722-6900
  • Fax: 706-722-5118
Mailing address:
  • Phone: 706-722-6900
  • Fax: 706-722-5118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number043510
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number13568
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: