Healthcare Provider Details

I. General information

NPI: 1790245801
Provider Name (Legal Business Name): BRIDGET ELISE WILSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2019
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 EUCLID AVE # R3
CLEVELAND OH
44195-4502
US

IV. Provider business mailing address

5777 E MAYO BLVD
PHOENIX AZ
85054-4502
US

V. Phone/Fax

Practice location:
  • Phone: 216-444-9410
  • Fax: 216-442-5975
Mailing address:
  • Phone: 480-301-8000
  • Fax:

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 StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number65897
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number35.150471
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: