Provider Demographics
NPI:1174756605
Name:BENJAMIN R. WILSON, MD, PC
Entity type:Organization
Organization Name:BENJAMIN R. WILSON, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-851-8908
Mailing Address - Street 1:PO BOX 3275
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-0275
Mailing Address - Country:US
Mailing Address - Phone:503-851-8908
Mailing Address - Fax:503-304-4361
Practice Address - Street 1:465 COMMERCIAL ST NE STE 150
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3414
Practice Address - Country:US
Practice Address - Phone:503-304-4358
Practice Address - Fax:503-304-4361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-01
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR15965-7Medicaid
OR15965-7Medicaid
C94087Medicare UPIN