Basic Information
| Provider Information | |||||||||
| NPI: | 1619974672 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27 | ||||||||
| Address2: | |||||||||
| City: | MANVILLE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028380027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009270002 | ||||||||
| FaxNumber: | 6038901236 | ||||||||
| Practice Location | |||||||||
| Address1: | 106 NATE WHIPPLE HWY | ||||||||
| Address2: | |||||||||
| City: | CUMBERLAND | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028641403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4016582020 | ||||||||
| FaxNumber: | 4016583612 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2005 | ||||||||
| LastUpdateDate: | 02/08/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD10225 | RI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7008327 | 05 | RI | MEDICAID |