Basic Information
| Provider Information | |||||||||
| NPI: | 1194765651 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1420 STEPHENSON HWY | ||||||||
| Address2: | SUITE 400 - CREDENTIALING | ||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480831189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485815974 | ||||||||
| FaxNumber: | 2485815640 | ||||||||
| Practice Location | |||||||||
| Address1: | 4160 JOHN R ST | ||||||||
| Address2: | STE 615 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137454195 | ||||||||
| FaxNumber: | 3139938669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 02/06/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 4301023556 | MI | Y | Allopathic & Osteopathic Physicians | Surgery | 2086S0102X | 4301023556 | MI | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 208G00000X | 4301023556 | MI | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
No ID Information.