Healthcare Provider Details

I. General information

NPI: 1477878072
Provider Name (Legal Business Name): MATTHEW MCEWEN WILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2010
Last Update Date: 07/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR PALLIATIVE MEDICINE
LEBANON NH
03756-1000
US

IV. Provider business mailing address

1 MEDICAL CENTER DR PALLIATIVE MEDICINE
LEBANON NH
03756-1000
US

V. Phone/Fax

Practice location:
  • Phone: 603-650-5402
  • Fax:
Mailing address:
  • Phone: 603-650-5402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number052321
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number17741
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: