Basic Information
| Provider Information | |||||||||
| NPI: | 1740363241 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHRISTOPHER S WILSON MDSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4555 W SCHROEDER DR | ||||||||
| Address2: | #170 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532231475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143653210 | ||||||||
| FaxNumber: | 4143653225 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 S 90TH ST | ||||||||
| Address2: | #102 | ||||||||
| City: | WEST ALLIS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142578573 | ||||||||
| FaxNumber: | 4142578505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2006 | ||||||||
| LastUpdateDate: | 03/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4142578573 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 32453700 | 05 | WI | MEDICAID |