Provider Demographics
NPI:1659376267
Name:WILSON, STEPHEN (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
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:PO BOX 806325
Mailing Address - Street 2:
Mailing Address - City:ST CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080
Mailing Address - Country:US
Mailing Address - Phone:586-563-3300
Mailing Address - Fax:586-563-3313
Practice Address - Street 1:24345 HARPER AVE
Practice Address - Street 2:
Practice Address - City:ST CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080
Practice Address - Country:US
Practice Address - Phone:586-563-3300
Practice Address - Fax:586-563-3313
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2008-07-23
Deactivation Date:2006-04-04
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
MISW061846208100000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4332250Medicaid
MI5614160001OtherMC NCS
MI2505012031OtherBCBS OF MI
MI4332250 10Medicaid
MI1932129319OtherDMENSION
MI540E019050OtherBCBSM DME
MI4332250Medicaid
MIG54181Medicare UPIN
MI540E019050OtherBCBSM DME