Healthcare Provider Details

I. General information

NPI: 1891469359
Provider Name (Legal Business Name): PHOEBE ANN WILSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: PHOEBE ANN DODGE M.D.

II. Dates (important events)

Enumeration Date: 08/06/2021
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46591 ROMEO PLANK RD
MACOMB MI
48044-5742
US

IV. Provider business mailing address

46591 ROMEO PLANK RD
MACOMB MI
48044-5742
US

V. Phone/Fax

Practice location:
  • Phone: 586-228-0130
  • Fax:
Mailing address:
  • Phone: 586-228-0130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301518253
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: