MEDICARE: MR. JACK KENNEY WILSON JR. 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	207R00000X	Internal Medicine Physician	16755	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	02701	OTHER	NC	BCBS NC
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356349559
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JACK KENNEY WILSON JR. MD

Provider Business Mailing Address
First Line	:	637 S KERR AVE
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28403-8423
Country	:	US
Telephone Number	:	910-799-1810
Fax Number	:	910-452-2571

Provider Business Practice Location Address
First Line	:	637 S KERR AVE
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28403-8423
Country	:	US
Telephone Number	:	910-799-1810
Fax Number	:	910-452-2571

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

Provider Enumeration Date	:	07/12/2005
Last Update Date	:	09/20/2012

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