Provider Demographics
NPI:1215161377
Name:MARY WILSON PHYSICIAN PC
Entity type:Organization
Organization Name:MARY WILSON PHYSICIAN PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-439-1958
Mailing Address - Street 1:14 E 69TH STREET.
Mailing Address - Street 2:MEDICAL OFFICE
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4964
Mailing Address - Country:US
Mailing Address - Phone:212-439-1958
Mailing Address - Fax:212-439-6718
Practice Address - Street 1:14 E 69TH STREET.
Practice Address - Street 2:MEDICAL OFFICE
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4964
Practice Address - Country:US
Practice Address - Phone:212-439-1958
Practice Address - Fax:212-439-6718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-05
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY320201Medicare PIN