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General NPI Number Information
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NPI Number | 1093934267
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Entity Type | Individual
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Provider Name | JULIE MARIE WILSON D.O.
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Gender | Female
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Dates
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Enumeration Date | 04/25/2007
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Last Update Date | 10/16/2024
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Provider Practice Location Address
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Address Line | 1179 E PARIS AVE SE STE 100
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City | GRAND RAPIDS
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State | MI
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Zip | 49546-3682
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Country | US
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Telephone | 616-400-5433
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Fax | 616-320-2034
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Provider Business Mailing Address
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Address Line | 1179 E PARIS AVE SE STE 100
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City | GRAND RAPIDS
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State | MI
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Zip | 49546-3682
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Country | US
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Telephone | 616-400-5433
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Fax | 616-360-2034
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207PE0004X
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Taxonomy Name | Emergency Medical Services (Emergency Medicine) Physician
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License Number | 5101015505
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 2084A0401X
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Taxonomy Name | Addiction Medicine (Psychiatry & Neurology) Physician
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License Number | 5101015505
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License Number State | MI
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