MEDICARE: BRENT A 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	2084P0800X	Psychiatry Physician	059350	GA
2	2084P0800X	Psychiatry Physician	DR.0053468	CO

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	:	1811186034
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENT A WILSON MD

Provider Business Mailing Address
First Line	:	800 PEACHTREE ST NE
Second Line	:	APT 1303
City	:	ATLANTA
State	:	GA
Zip	:	30308-1245
Country	:	US
Telephone Number	:	410-533-2000
Fax Number	:	480-287-8015

Provider Business Practice Location Address
First Line	:	800 PEACHTREE ST NE
Second Line	:	APT 1303
City	:	ATLANTA
State	:	GA
Zip	:	30308-1245
Country	:	US
Telephone Number	:	410-533-2000
Fax Number	:	480-287-8015

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

Provider Enumeration Date	:	10/24/2007
Last Update Date	:	06/19/2014

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Directions to “ BRENT A WILSON MD” Practice Location

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