MEDICARE: DR. BRIAN GUY WILSON M.D.

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	207KA0200X	Allergy Physician	MD.15516R	LA
2	207RA0201X	Allergy & Immunology (Internal Medicine) Physician	ME82516	FL

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	:	1760433247
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRIAN GUY WILSON M.D.

Provider Business Mailing Address
First Line	:	PO BOX 13058
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32317-3058
Country	:	US
Telephone Number	:	850-656-7720
Fax Number	:	850-656-7729

Provider Business Practice Location Address
First Line	:	2619 CENTENNIAL BLVD STE 103
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32308-0590
Country	:	US
Telephone Number	:	850-656-7720
Fax Number	:	850-656-7729

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

Provider Enumeration Date	:	05/12/2006
Last Update Date	:	05/02/2011

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