Healthcare Provider Details

I. General information

NPI: 1093934267
Provider Name (Legal Business Name): JULIE MARIE WILSON D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1179 E PARIS AVE SE STE 100
GRAND RAPIDS MI
49546-3682
US

IV. Provider business mailing address

1179 E PARIS AVE SE STE 100
GRAND RAPIDS MI
49546-3682
US

V. Phone/Fax

Practice location:
  • Phone: 616-400-5433
  • Fax: 616-320-2034
Mailing address:
  • Phone: 616-400-5433
  • Fax: 616-360-2034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number5101015505
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number5101015505
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: