Provider Demographics
NPI:1427012178
Name:WILSON, ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 MERCY DR.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-1878
Mailing Address - Country:US
Mailing Address - Phone:231-830-2727
Mailing Address - Fax:231-830-2764
Practice Address - Street 1:1400 MERCY DR.
Practice Address - Street 2:SUITE 100
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1878
Practice Address - Country:US
Practice Address - Phone:231-733-1326
Practice Address - Fax:231-733-5212
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301051068208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2808010Medicaid
MI4301051068OtherSTATE LICENSE
MI2808010Medicaid
MI4301051068OtherSTATE LICENSE