Healthcare Provider Details

I. General information

NPI: 1740363241
Provider Name (Legal Business Name): CHRISTOPHER S WILSON MDSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 03/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 S 90TH ST #102
WEST ALLIS WI
53227
US

IV. Provider business mailing address

4555 W SCHROEDER DR #170
MILWAUKEE WI
53223-1475
US

V. Phone/Fax

Practice location:
  • Phone: 414-257-8573
  • Fax: 414-257-8505
Mailing address:
  • Phone: 414-365-3210
  • Fax: 414-365-3225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER S WILSON
Title or Position: OWNER/PRESIDENT
Credential: MD
Phone: 414-257-8573