MEDICARE: JANE ELLEN WILSON 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	207Q00000X	Family Medicine Physician	D0061584	MD
2	2083P0901X	Public Health & General Preventive Medicine Physician	D0061584	MD

General Provider Information

NPI Number	:	1720257991
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JANE ELLEN WILSON M.D.

Provider Business Mailing Address
First Line	:	3501 SINCLAIR LN
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21213-2029
Country	:	US
Telephone Number	:	410-732-8800
Fax Number	:	410-534-2392

Provider Business Practice Location Address
First Line	:	900 CATON AVE
Second Line	:	MAILBOX 081
City	:	BALTIMORE
State	:	MD
Zip	:	21229-5201
Country	:	US
Telephone Number	:	443-703-3200
Fax Number	:	443-703-3201

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

Provider Enumeration Date	:	02/21/2008
Last Update Date	:	11/10/2015

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