Provider Demographics
NPI:1972581858
Name:WILSON, THERESE M (MD)
Entity type:Individual
Prefix:DR
First Name:THERESE
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9146
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:120 IRMC DR STE 130
Practice Address - Street 2:
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-3674
Practice Address - Country:US
Practice Address - Phone:724-471-7100
Practice Address - Fax:724-471-7111
Is Sole Proprietor?:No
Enumeration Date:2006-01-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD419534207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PABW3042289OtherDEA
PABW3042289OtherDEA
G07025Medicare UPIN
PA102633104Medicaid
PA25-1716306OtherINFORMED
PA25-1716306OtherSOUTH CENTRAL PREFERRED
PA25-1716306OtherFIRST HEALTH
PA25-1716306OtherINTERGROUP
PAMD419534OtherLICENSE
PA1540842OtherGATEWAY
PA25-1716306OtherHEALTHNET/TRICARE
PA867633OtherMEDICARE GROUP #
PA943003-01OtherCAREFIRST MD
PA25-1716306OtherDEVON
PA25-1716306OtherGREATWEST HEALTHCARE
PA50005193OtherCAPITAL BLUECROSS
PA001922262 0001Medicaid
PA064182LN7Medicare PIN
PA1007307260034OtherMEDICAID GROUP #
PAP00700663OtherRAILROAD MEDICARE
G07025Medicare UPIN
PA1319738OtherHIGHMARK BLUE SHIELD
PA262930OtherUNISON
PABW3042289OtherDEA
PA120420421OtherDEPT OF LABOR
PA2188604OtherMAMSI
PA7119265OtherAETNA NON-HMO