Provider Demographics
NPI:1073273645
Name:WILSON, ERIK
Entity Type:Individual
Prefix:
First Name:ERIK
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30800 CHAGRIN BLVD
Mailing Address - Street 2:
Mailing Address - City:PEPPER PIKE
Mailing Address - State:OH
Mailing Address - Zip Code:44124-5925
Mailing Address - Country:US
Mailing Address - Phone:216-591-0324
Mailing Address - Fax:216-591-1243
Practice Address - Street 1:30800 CHAGRIN BLVD
Practice Address - Street 2:
Practice Address - City:PEPPER PIKE
Practice Address - State:OH
Practice Address - Zip Code:44124-5925
Practice Address - Country:US
Practice Address - Phone:216-591-0324
Practice Address - Fax:216-591-1243
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-23
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2877463Medicaid