Provider Demographics
NPI:1467547141
Name:WILSON INTERVENTIONAL CLINIC PA
Entity Type:Organization
Organization Name:WILSON INTERVENTIONAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:B
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-425-3737
Mailing Address - Street 1:PO BOX 2008
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72654-2008
Mailing Address - Country:US
Mailing Address - Phone:870-425-3737
Mailing Address - Fax:870-425-3742
Practice Address - Street 1:628 HOSPITAL DR STE 3D
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-2952
Practice Address - Country:US
Practice Address - Phone:870-425-3737
Practice Address - Fax:870-425-3742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN-82972085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR149277002Medicaid
AR5C771Medicare PIN