Healthcare Provider Details

I. General information

NPI: 1285669531
Provider Name (Legal Business Name): DOUGLAS GRAY WILSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 11/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1163 COUNTRY CLUB RD MONONGAHELA VALLEY HOSPITAL
MONONGAHELA PA
15063-1013
US

IV. Provider business mailing address

800 VINIAL ST SUITE B407A
PITTSBURGH PA
15212-5151
US

V. Phone/Fax

Practice location:
  • Phone: 724-258-1050
  • Fax:
Mailing address:
  • Phone: 412-323-4400
  • Fax: 412-323-4418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD043611E
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: