Healthcare Provider Details

I. General information

NPI: 1649239260
Provider Name (Legal Business Name): THOMAS WILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 01/11/2021
Certification Date: 01/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18599 LAKE SHORE BLVD
CLEVELAND OH
44119-1093
US

IV. Provider business mailing address

24701 EUCLID AVE 3RD FLOOR
EUCLID OH
44117-1714
US

V. Phone/Fax

Practice location:
  • Phone: 216-844-3800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35-049077
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number35-049077
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: