Healthcare Provider Details

I. General information

NPI: 1285602136
Provider Name (Legal Business Name): ROBERT C WILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 03/01/2022
Certification Date: 03/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 HOSPITAL DR
MACON GA
31217-3838
US

IV. Provider business mailing address

PO BOX 235019
MONTGOMERY AL
36123-5019
US

V. Phone/Fax

Practice location:
  • Phone: 478-746-7577
  • Fax:
Mailing address:
  • Phone: 334-279-1450
  • Fax: 334-395-4110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036042
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number036042
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: