Charles R Wilson, D.O.
Individual provider Active NPI Family Medicine Physician · Sour Lake, TX
NPI 1790799807 · NPPES record last updated May 1, 2013
Key facts
- NPI
- 1790799807
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Family Medicine Physician 207Q00000X
- License
- H8516 (TX)
- Practice address
- 327 Morris Rd W
Sour Lake, TX 77659-9774 - Phone
- (409) 753-2577
- NPI assigned
- Jul 27, 2006
- Sex
- Male
- Sole proprietor
- Yes
Organizations & group practices 11
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in TX
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20040616000511 | TX | Practitioner - Family Practice |
1254315344 | Reassigns benefits to 2 organizations |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Osteopathy, Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| H8516 | TX | MD | Family Medicine Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Tyler County Hospital District | Current |
Accepting new patients | |
| Tyler County Hospital District | Current | Accepting new patients | |
| Tyler County Hospital District | Current |
Accepting new patients | |
| Pioneer Physician Services PA | Past | Accepting new patients | |
| Pioneer Emergency Medicine Associates PA | Past | Accepting new patients | |
| Cannon Emergency Physicians | Past | Accepting new patients | |
| Texas Emergency Room Services , PA | Past | Accepting new patients | |
| Texas Emergency Room Services, PA | Past | Accepting new patients | |
| Southeast Emergency Physician Associates, P.a. | Past | Accepting new patients | |
| Leatherland Emergency Physicians PLLC | Past | Accepting new patients |
Locations
1100 W Bluff St
Woodville, TX 75979
Phone (409) 283-6400
Interoperability endpoints
- charleswilson@tchfamilym.allscriptsdirect.net
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | H8516 | TX | Yes |
Addresses
Primary practice location
327 Morris Rd W
Sour Lake, TX 77659-9774
Mailing address
327 Morris Rd W
Sour Lake, TX 77659-9774
Phone (409) 753-2577
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 139218516 | Medicaid | TX |
Other providers in Sour Lake, TX
All providers in Sour Lake, TX · Family Medicine Physician in Texas
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on May 1, 2013. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.