Provider Demographics
NPI:1902932478
Name:WILSON MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:WILSON MEDICAL CENTER, INC.
Other - Org Name:STANTONSBURG MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CHIEF EXECUTIVE OFFIC
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-399-8193
Mailing Address - Street 1:312 SOUTH MAIN STREET
Mailing Address - Street 2:P.O. BOX 400
Mailing Address - City:STANTONSBURG
Mailing Address - State:NC
Mailing Address - Zip Code:27883-0400
Mailing Address - Country:US
Mailing Address - Phone:252-238-2757
Mailing Address - Fax:252-399-8829
Practice Address - Street 1:312 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:STANTONSBURG
Practice Address - State:NC
Practice Address - Zip Code:27883-0400
Practice Address - Country:US
Practice Address - Phone:252-238-2757
Practice Address - Fax:252-399-8829
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WILSON MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-26
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0232UOtherNC BLUE CROSS PROVIDER NO
NC890232UMedicaid
NC0232UOtherNC BLUE CROSS PROVIDER NO