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General NPI Number Information
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NPI Number | 1467547141
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Entity Type | Organization
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Legal Business Name | WILSON INTERVENTIONAL CLINIC PA
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Dates
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Enumeration Date | 10/04/2006
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Last Update Date | 08/27/2010
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Provider Practice Location Address
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Address Line | 628 HOSPITAL DR STE 3D
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City | MOUNTAIN HOME
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State | AR
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Zip | 72653-2952
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Country | US
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Telephone | 870-425-3737
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Fax | 870-425-3742
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Provider Business Mailing Address
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Address Line | PO BOX 2008
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City | MOUNTAIN HOME
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State | AR
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Zip | 72654-2008
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Country | US
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Telephone | 870-425-3737
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Fax | 870-425-3742
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Authorized Official
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Title or Position | PRESIDENT
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Name | MATTHEW B WILSON
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Credential | MD
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Telephone | 870-425-3737
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0204X
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Taxonomy Name | Vascular & Interventional Radiology Physician
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License Number | N-8297
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License Number State | AR
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