Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207X00000X | Orthopaedic Surgeon | 041498 | GA |
N | 207XX0005X | Sports Medicine Orthopaedic Surgeon | 041498 | GA |
NPI | 1013000801 |
---|---|
Provider Name | Dr. Michael D Wilson |
First Address | Dalton, GA 30720-2588 |
Second Address | Dalton, GA 30720-2588 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/10/2006 |
Last Update Date | 19/12/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00869525B | (05) | GA |
927802 | BCBS EDI (01) | GA |
H17572 | (02) | GA |