MEDICARE: GEORGE WILSON M.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	25MA02887700	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417056276
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GEORGE WILSON M.D.

Provider Business Mailing Address
First Line	:	4 PRINCESS RD
Second Line	:	SUITE #207
City	:	LAWRENCEVILLE
State	:	NJ
Zip	:	08648-2322
Country	:	US
Telephone Number	:	609-243-0445
Fax Number	:	609-844-1092

Provider Business Practice Location Address
First Line	:	905 HERRONTOWN RD
Second Line	:	PRINCETON HOUSE BEHAVIORAL HEALTH
City	:	PRINCETON
State	:	NJ
Zip	:	08540-1901
Country	:	US
Telephone Number	:	609-497-3300
Fax Number	:	609-497-3370

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

Provider Enumeration Date	:	09/21/2006
Last Update Date	:	01/22/2009

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