Provider Demographics
NPI:1740363241
Name:CHRISTOPHER S WILSON MDSC
Entity type:Organization
Organization Name:CHRISTOPHER S WILSON MDSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:S
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-257-8573
Mailing Address - Street 1:4555 W SCHROEDER DR
Mailing Address - Street 2:#170
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53223-1475
Mailing Address - Country:US
Mailing Address - Phone:414-365-3210
Mailing Address - Fax:414-365-3225
Practice Address - Street 1:2400 S 90TH ST
Practice Address - Street 2:#102
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227
Practice Address - Country:US
Practice Address - Phone:414-257-8573
Practice Address - Fax:414-257-8505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32453700Medicaid