1104883701 NPI number — DR. MATTHEW W WILSON MD

Table of content: DR. MATTHEW W WILSON MD (NPI 1104883701)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104883701 NPI number — DR. MATTHEW W WILSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
MATTHEW
Provider Middle Name:
W
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104883701
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/21/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1068 CRESTHAVEN RD STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38119-0809
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-866-8864
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
930 MADISON AVE STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38103-3452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-448-6650
Provider Business Practice Location Address Fax Number:
901-302-2486
Provider Enumeration Date:
04/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  31289 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 180054 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00120854 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1104883701 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 138964001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1104883701 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003180582A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: Q003849 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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