Basic Information
| Provider Information | |||||||||
| NPI: | 1619996121 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | SUZANNE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 PAGE ROAD | ||||||||
| Address2: | |||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283748798 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102955511 | ||||||||
| FaxNumber: | 9102955481 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 PAGE ROAD | ||||||||
| Address2: | |||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283748798 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102955511 | ||||||||
| FaxNumber: | 9102955481 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 05/17/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 01975 | NC | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | N01975 | 01 | SC | SC MEDICAID | OTHER | 144NO | 01 | NC | BCBS | OTHER | 5905677 | 05 | NC | MEDICAID | 0407048 | 01 | NC | EVERCARE PROVIDER # | OTHER | 195533 | 01 | NC | MEDCOST | OTHER | FH1100235 | 01 | NC | FIRSTCAROLINA | OTHER |