Healthcare Provider Details

I. General information

NPI: 1639284300
Provider Name (Legal Business Name): WILLIAM L WILSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 03/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 HERRICK ST LAHEY AT BEVERLY HOSPITAL
BEVERLY MA
01915-1790
US

IV. Provider business mailing address

85 HERRICK ST LAHEY AT BEVERLY HOSPITAL
BEVERLY MA
01915-1790
US

V. Phone/Fax

Practice location:
  • Phone: 978-922-3000
  • Fax: 978-921-7048
Mailing address:
  • Phone: 978-922-3000
  • Fax: 978-921-7048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number22648
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number238644
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number238644
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: