Provider Demographics
NPI:1184980690
Name:WILSON, LIZ (DO)
Entity type:Individual
Prefix:
First Name:LIZ
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:50505 SCHOENHERR RD
Mailing Address - Street 2:SUITE 340
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-3140
Mailing Address - Country:US
Mailing Address - Phone:586-731-8400
Mailing Address - Fax:586-731-8406
Practice Address - Street 1:50505 SCHOENHERR RD
Practice Address - Street 2:SUITE 340
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-3140
Practice Address - Country:US
Practice Address - Phone:586-731-8400
Practice Address - Fax:586-731-8406
Is Sole Proprietor?:No
Enumeration Date:2012-04-09
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101019844208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP24580036Medicare PIN