Healthcare Provider Details

I. General information

NPI: 1609844653
Provider Name (Legal Business Name): SAMUEL MAYHEW WILSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 06/21/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1073 MEDICAL RIDGE RD
CLINTON SC
29325-4542
US

IV. Provider business mailing address

300 E MCBEE AVE FL 4
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 864-833-3557
  • Fax: 864-833-7724
Mailing address:
  • Phone: 864-522-8603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number33377
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: