MEDICARE: MR. MARK WILSON

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	261Q00000X	Clinic/Center	A-6418104	PA

General Provider Information

NPI Number	:	1750736088
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK WILSON

Provider Business Mailing Address
First Line	:	5313 OGDEN ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19139-1438
Country	:	US
Telephone Number	:	215-600-9477
Fax Number	:	215-921-8499

Provider Business Practice Location Address
First Line	:	5313 OGDEN ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19139-1438
Country	:	US
Telephone Number	:	215-600-9477
Fax Number	:	215-921-8499

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

Provider Enumeration Date	:	04/23/2016
Last Update Date	:	04/23/2016

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