Healthcare Provider Details

I. General information

NPI: 1982698155
Provider Name (Legal Business Name): ROBERT JOSEPH WILSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2005
Last Update Date: 06/25/2021
Certification Date: 06/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1855 TANNER WAY
HARRIMAN TN
37748-8302
US

IV. Provider business mailing address

1855 TANNER WAY
HARRIMAN TN
37748-8302
US

V. Phone/Fax

Practice location:
  • Phone: 865-376-6272
  • Fax: 865-376-0341
Mailing address:
  • Phone: 865-376-6272
  • Fax: 865-376-0341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number30880
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: