MEDICARE: MARK ROBERT WILCOX DPT

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	225100000X	Physical Therapist	1990	SD
2	225100000X	Physical Therapist	12361	MN

General Provider Information

NPI Number	:	1629505359
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK ROBERT WILCOX DPT

Provider Business Mailing Address
First Line	:	4200 DAHLBERG DR STE 300
Second Line	:
City	:	GOLDEN VALLEY
State	:	MN
Zip	:	55422-4841
Country	:	US
Telephone Number	:	952-512-5600
Fax Number	:

Provider Business Practice Location Address
First Line	:	4570 CHURCHILL ST STE 300
Second Line	:
City	:	SHOREVIEW
State	:	MN
Zip	:	55126-2274
Country	:	US
Telephone Number	:	651-481-1071
Fax Number	:	651-481-0042

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

Provider Enumeration Date	:	05/12/2017
Last Update Date	:	10/25/2021

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