Healthcare Provider Details

I. General information

NPI: 1821520396
Provider Name (Legal Business Name): MATTHEW ALAN WILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 07/11/2025
Certification Date: 07/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9263 MEDICAL PLAZA DR STE E
CHARLESTON SC
29406-7112
US

IV. Provider business mailing address

530 S JACKSON ST RM C2A03
LOUISVILLE KY
40202-1675
US

V. Phone/Fax

Practice location:
  • Phone: 888-975-6390
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number01096323A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number85658
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: