Healthcare Provider Details

I. General information

NPI: 1285673590
Provider Name (Legal Business Name): CAROLINE L WILSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 04/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2875 W MARKET ST
FAIRLAWN OH
44333-4064
US

IV. Provider business mailing address

525 E MARKET ST PO BOX 2090
AKRON OH
44304-1619
US

V. Phone/Fax

Practice location:
  • Phone: 330-864-1916
  • Fax: 330-864-1924
Mailing address:
  • Phone: 330-996-8603
  • Fax: 330-996-0359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35042302
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: