MEDICARE: PHILLIP EGBERT WILSON M.D., PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	7471471-1205	UT

General Provider Information

NPI Number	:	1265686281
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILLIP EGBERT WILSON M.D., PH.D.

Provider Business Mailing Address
First Line	:	324 10TH AVE STE 154
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84103-2876
Country	:	US
Telephone Number	:	801-408-8500
Fax Number	:

Provider Business Practice Location Address
First Line	:	324 10TH AVE STE 154
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84103-2876
Country	:	US
Telephone Number	:	801-408-8500
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/05/2008
Last Update Date	:	06/13/2012

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