Basic Information
| Provider Information | |||||||||
| NPI: | 1790759819 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MSPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 587 COACH HILL CT | ||||||||
| Address2: | |||||||||
| City: | WEST CHESTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193801735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4845741434 | ||||||||
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| Practice Location | |||||||||
| Address1: | 525 W CHESTER PIKE | ||||||||
| Address2: | |||||||||
| City: | HAVERTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190834539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104498400 | ||||||||
| FaxNumber: | 6104496392 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT016637 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1605505 | 01 | PA | BLUE SHIELD | OTHER | 2283570000 | 01 | PA | IBC | OTHER |