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General NPI Number Information
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NPI Number | 1285648683
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Entity Type | Organization
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Legal Business Name | TALLAHASSEE ALLERGY, ASTHMA & IMMUNOLOGY, LLC
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Dates
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Enumeration Date | 07/28/2006
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Last Update Date | 05/02/2011
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Provider Practice Location Address
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Address Line | 2619 CENTENNIAL BLVD STE 103
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City | TALLAHASSEE
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State | FL
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Zip | 32308-0590
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Country | US
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Telephone | 850-656-7720
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Fax | 850-656-7729
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Provider Business Mailing Address
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Address Line | PO BOX 13058
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City | TALLAHASSEE
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State | FL
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Zip | 32317-3058
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Country | US
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Telephone | 850-656-7720
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Fax | 850-656-7729
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Authorized Official
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Title or Position | OWNER
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Name | BRIAN GUY WILSON
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Credential | M.D.
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Telephone | 850-656-7720
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207K00000X
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Taxonomy Name | Allergy & Immunology Physician
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License Number | ME82516
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License Number State | FL
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