=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598382640
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIC LYNN WILKERSON II MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2020
-----------------------------------------------------
Last Update Date | 07/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 S WASHINGTON AVE
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38701-4719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-827-9904
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 580 WILDWOOD DR
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38701-7400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-827-9904
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | T-4157
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------