Provider Demographics
NPI:1073096335
Name:TH WILSON NEUROMONITORING PLLC
Entity Type:Organization
Organization Name:TH WILSON NEUROMONITORING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:G
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-310-7334
Mailing Address - Street 1:DEPT 880285 PO BOX 29654
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85038-9650
Mailing Address - Country:US
Mailing Address - Phone:800-310-7334
Mailing Address - Fax:
Practice Address - Street 1:3536 HELEN AVENUE DR
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-3426
Practice Address - Country:US
Practice Address - Phone:800-310-7334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-12
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic MedicineGroup - Single Specialty