Provider Demographics
NPI:1649239260
Name:WILSON, THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
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 1:24701 EUCLID AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-1714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18599 LAKE SHORE BLVD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44119-1093
Practice Address - Country:US
Practice Address - Phone:216-844-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-049077207RC0000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0607927Medicaid
OH2597481OtherUNITED HEALTHCARE
OH341313510TWOtherSUMMACARE
OH4344500OtherAETNA
OH000000503655OtherANTHEM
OH264168OtherFEDERAL BLACK LUNG
OH364138OtherWELLCARE
OH741761OtherBUCKEYE
OHP00358874OtherRAILROAD MEDICARE
OH000000130210OtherANTHEM
OH000000221214OtherUNISON
OH18959OtherQUALCHOICE
OH18959OtherQUALCHOICE
OHWI4171122Medicare PIN
OH264168OtherFEDERAL BLACK LUNG
OHWI0656224Medicare ID - Type Unspecified