=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154524502
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILSON S. COMER, JR., M.D., P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2007
-----------------------------------------------------
Last Update Date | 11/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 867 WASHINGTON ST
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27605-1255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-833-5867
-----------------------------------------------------
Fax | 919-833-5859
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 867 WASHINGTON ST
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27605-1255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-833-5867
-----------------------------------------------------
Fax | 919-833-5859
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. WILSON SIDNEY COMER JR.
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 919-833-5867
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 21761
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------