Provider Demographics
NPI:1831207539
Name:WILSON, GREGORY S (MS)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:S
Last Name:WILSON
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8028 RITCHIE HWY
Mailing Address - Street 2:SUITE # 311
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-1075
Mailing Address - Country:US
Mailing Address - Phone:410-590-9462
Mailing Address - Fax:410-590-9464
Practice Address - Street 1:8028 RITCHIE HWY
Practice Address - Street 2:SUITE # 311
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-1075
Practice Address - Country:US
Practice Address - Phone:410-590-9462
Practice Address - Fax:410-590-9464
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD00658231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD86RVHEOtherCAREFIRST GROUP
MD8632OtherBLUE CHOICE GROUP
MD413159200Medicaid
MD86RVHEOtherCAREFIRST GROUP