Provider Demographics
NPI:1003881053
Name:WILSON, HALLIE J (DO)
Entity Type:Individual
Prefix:DR
First Name:HALLIE
Middle Name:J
Last Name:WILSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 730
Mailing Address - Street 2:406 E ELM ST
Mailing Address - City:CARSON CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48811
Mailing Address - Country:US
Mailing Address - Phone:989-584-3131
Mailing Address - Fax:989-584-6734
Practice Address - Street 1:114 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:MI
Practice Address - Zip Code:48847
Practice Address - Country:US
Practice Address - Phone:989-875-4166
Practice Address - Fax:989-875-3600
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011981207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3381288Medicaid
G19732Medicare UPIN
MI3381288Medicaid