Provider Demographics
NPI:1922011659
Name:WILSON, MICHELE (MD)
Entity Type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 COBBS CREEK PARKWAY
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19139-3723
Mailing Address - Country:US
Mailing Address - Phone:215-476-2223
Mailing Address - Fax:215-476-3981
Practice Address - Street 1:225 COBBS CREEK PARKWAY
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19139-3723
Practice Address - Country:US
Practice Address - Phone:215-476-2223
Practice Address - Fax:215-476-3981
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-062756-L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA005582Medicare ID - Type UnspecifiedMEDICARE
PAD78206Medicare UPIN