Healthcare Provider Details

I. General information

NPI: 1568402121
Provider Name (Legal Business Name): MARK CHRISTOPHER WILSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 05/10/2022
Certification Date: 05/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 VIRGINIA AVE SUITE A
CONNERSVILLE IN
47331-2921
US

IV. Provider business mailing address

2561 KANLOW DR
ANTIOCH TN
37013-3951
US

V. Phone/Fax

Practice location:
  • Phone: 615-585-5941
  • Fax:
Mailing address:
  • Phone: 615-941-5204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD0000039499
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD0000039499
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: