Healthcare Provider Details

I. General information

NPI: 1427462761
Provider Name (Legal Business Name): PHILLIP RYAN WILSON II M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2014
Last Update Date: 08/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 ASHLEY AVE ROOM 202 MAIN HOSPITAL
CHARLESTON SC
29425
US

IV. Provider business mailing address

PO BOX 751461
CHARLOTTE NC
28275-1461
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-2322
  • Fax:
Mailing address:
  • Phone: 843-792-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberLL37030
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number37030
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: