MEDICARE: JAMES KEENAN WILSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	14441	MS
2	208D00000X	General Practice Physician	14441	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003841354
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES KEENAN WILSON MD

Provider Business Mailing Address
First Line	:	307 COLLEGE ST
Second Line	:
City	:	WINONA
State	:	MS
Zip	:	38967-1901
Country	:	US
Telephone Number	:	662-508-5061
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 VETERANS MEMORIAL BLVD S
Second Line	:
City	:	EUPORA
State	:	MS
Zip	:	39744-2215
Country	:	US
Telephone Number	:	662-258-6221
Fax Number	:	662-258-9291

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	06/13/2016

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