Provider Demographics
NPI:1164579975
Name:WILSON, ELEANOR MCKENNA PITT (MD)
Entity Type:Individual
Prefix:
First Name:ELEANOR
Middle Name:MCKENNA PITT
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELEANOR
Other - Middle Name:
Other - Last Name:PITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 64442
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4442
Mailing Address - Country:US
Mailing Address - Phone:410-706-4613
Mailing Address - Fax:410-706-4619
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-706-4613
Practice Address - Fax:410-706-4619
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN43321207R00000X
MDD78603207RI0200X
DCMD042630207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD514029300Medicaid
MDS062-0580OtherCAREFIRST BC/BS