MEDICARE: GLEN PAUL WILCOXSON 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	207Q00000X	Family Medicine Physician	5915	AL

General Provider Information

NPI Number	:	1689719890
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLEN PAUL WILCOXSON MD

Provider Business Mailing Address
First Line	:	1 TIMBER WAY
Second Line	:	STE 102
City	:	DAPHNE
State	:	AL
Zip	:	36527
Country	:	US
Telephone Number	:	251-447-0333
Fax Number	:	251-447-0009

Provider Business Practice Location Address
First Line	:	1 TIMBER WAY
Second Line	:	STE 102
City	:	DAPHNE
State	:	AL
Zip	:	36527
Country	:	US
Telephone Number	:	251-447-0333
Fax Number	:	251-447-0009

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

Provider Enumeration Date	:	02/21/2007
Last Update Date	:	07/08/2007

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