Healthcare Provider Details

I. General information

NPI: 1912368937
Provider Name (Legal Business Name): MICHAEL WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2016
Last Update Date: 04/07/2021
Certification Date: 04/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6071 W OUTER DR
DETROIT MI
48235-2624
US

IV. Provider business mailing address

6071 W OUTER DR
DETROIT MI
48235-2624
US

V. Phone/Fax

Practice location:
  • Phone: 313-966-1941
  • Fax: 313-966-4204
Mailing address:
  • Phone: 313-966-1941
  • Fax: 313-966-4204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberDO2874
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: