MEDICARE: DR. GARY MASON WILKES M.D.

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	35049560	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548265051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY MASON WILKES M.D.

Provider Business Mailing Address
First Line	:	28249 SHAKER BLVD
Second Line	:
City	:	PEPPER PIKE
State	:	OH
Zip	:	44124-5006
Country	:	US
Telephone Number	:	216-464-2795
Fax Number	:	216-765-0448

Provider Business Practice Location Address
First Line	:	23811 CHAGRIN BLVD
Second Line	:	STE 170
City	:	BEACHWOOD
State	:	OH
Zip	:	44122-5525
Country	:	US
Telephone Number	:	216-765-0440
Fax Number	:	216-765-0448

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/21/2005
Last Update Date	:	10/08/2009

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