Healthcare Provider Details

I. General information

NPI: 1033185491
Provider Name (Legal Business Name): ROBERT A WILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 09/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 E NORTH ST STE 16
GREENVILLE SC
29615-2437
US

IV. Provider business mailing address

4200 E N STREET, SUITE 16
GREENVILLE SC
29615
US

V. Phone/Fax

Practice location:
  • Phone: 864-292-2800
  • Fax: 864-292-2921
Mailing address:
  • Phone: 864-292-2800
  • Fax: 864-292-2921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License Number9726
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: