Healthcare Provider Details

I. General information

NPI: 1104178482
Provider Name (Legal Business Name): WILSON ANESTHESIA ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2012
Last Update Date: 10/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2430 BROOKSTONE CENTRE PKWY
COLUMBUS GA
31904-4501
US

IV. Provider business mailing address

PO BOX 8866
GREENSBORO NC
27419-0866
US

V. Phone/Fax

Practice location:
  • Phone: 706-494-7700
  • Fax: 706-494-8800
Mailing address:
  • Phone: 336-553-1659
  • Fax: 336-553-3994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: MR. CHARLES D WILSON
Title or Position: PRESIDENT
Credential:
Phone: 706-957-2782