MEDICARE: MR. JOHN WINKLE WILSON JR. 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	207R00000X	Internal Medicine Physician	3974	SC

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891750782
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN WINKLE WILSON JR. M.D.

Provider Business Mailing Address
First Line	:	PO BOX 50760
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29579-0013
Country	:	US
Telephone Number	:	843-234-5139
Fax Number	:	843-234-6822

Provider Business Practice Location Address
First Line	:	8002 MYRTLE TRACE DR
Second Line	:
City	:	CONWAY
State	:	SC
Zip	:	29526-8945
Country	:	US
Telephone Number	:	843-347-7227
Fax Number	:

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

Provider Enumeration Date	:	04/20/2006
Last Update Date	:	12/23/2010

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