MEDICARE: MICHAEL SCOTT WILDSTEIN 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	207XS0117X	Orthopaedic Surgery of the Spine Physician	24445	SC
2	207X00000X	Orthopaedic Surgery Physician	24445	SC

General Provider Information

NPI Number	:	1821102245
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL SCOTT WILDSTEIN MD

Provider Business Mailing Address
First Line	:	418 FOLLY RD
Second Line	:	SUITE C
City	:	CHARLESTON
State	:	SC
Zip	:	29412-2625
Country	:	US
Telephone Number	:	843-406-2771
Fax Number	:	843-406-2789

Provider Business Practice Location Address
First Line	:	418 FOLLY RD
Second Line	:	SUITE C
City	:	CHARLESTON
State	:	SC
Zip	:	29412-2625
Country	:	US
Telephone Number	:	843-406-2771
Fax Number	:	843-406-2789

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

Provider Enumeration Date	:	08/19/2006
Last Update Date	:	01/26/2015

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