Basic Information
| Provider Information | |||||||||
| NPI: | 1538394630 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 743904 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303743904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032967320 | ||||||||
| FaxNumber: | 8032967330 | ||||||||
| Practice Location | |||||||||
| Address1: | 8 RICHLAND MEDICAL PARK DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032566511 | ||||||||
| FaxNumber: | 8033765883 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2009 | ||||||||
| LastUpdateDate: | 06/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | TRN13691 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0011X | 45950 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RI0011X | 51981 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207R00000X | ME112912 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 519816 | 05 | SC | MEDICAID | 14K5A | 01 | FL | BCBSFL | OTHER | 005571300 | 05 | FL | MEDICAID | 003124179A | 05 | GA | MEDICAID |