Provider Demographics
NPI:1194765651
Name:WILSON, ROBERT F (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:F
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1420 STEPHENSON HWY
Mailing Address - Street 2:SUITE 400 - CREDENTIALING
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1189
Mailing Address - Country:US
Mailing Address - Phone:248-581-5974
Mailing Address - Fax:248-581-5640
Practice Address - Street 1:4160 JOHN R ST
Practice Address - Street 2:STE 615
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2020
Practice Address - Country:US
Practice Address - Phone:313-745-4195
Practice Address - Fax:313-993-8669
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2014-02-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301023556208600000X, 2086S0102X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P30630261Medicare PIN