MEDICARE: SALLY KING 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	207Q00000X	Family Medicine Physician	4301068222	MI

General Provider Information

NPI Number	:	1992711964
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SALLY KING WILSON MD

Provider Business Mailing Address
First Line	:	121 S COCHRAN AVE
Second Line	:	SUITE C
City	:	CHARLOTTE
State	:	MI
Zip	:	48813-1568
Country	:	US
Telephone Number	:	517-543-9095
Fax Number	:	517-543-3339

Provider Business Practice Location Address
First Line	:	121 S COCHRAN AVE
Second Line	:	SUITE C
City	:	CHARLOTTE
State	:	MI
Zip	:	48813-1568
Country	:	US
Telephone Number	:	517-543-9095
Fax Number	:	517-543-3339

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

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	02/29/2008

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