Provider Demographics
NPI:1275565251
Name:WILSON, MARC
Entity Type:Individual
Prefix:DR
First Name:MARC
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:PO BOX 64888
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4888
Mailing Address - Country:US
Mailing Address - Phone:800-889-4939
Mailing Address - Fax:
Practice Address - Street 1:815 E PRATT ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-4889
Practice Address - Country:US
Practice Address - Phone:410-637-5700
Practice Address - Fax:410-637-5661
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD46771207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD493150500Medicaid
MD445WMedicare PIN