MEDICARE: JGW3 MEDICAL PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician

General Provider Information

NPI Number	:	1235874033
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JGW3 MEDICAL PLLC

Provider Business Mailing Address
First Line	:	255 S 17TH ST STE 2701
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19103-6228
Country	:	US
Telephone Number	:	856-600-4011
Fax Number	:	714-333-2441

Provider Business Practice Location Address
First Line	:	255 S 17TH ST STE 2701
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19103-6228
Country	:	US
Telephone Number	:	856-600-4011
Fax Number	:	714-333-2441

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JOHN WILSON
Credential	:	MD
Telephone Number	:	856-600-4011

Provider Enumeration Date	:	05/05/2022
Last Update Date	:	05/05/2022

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