NPIMap

Individual provider Active NPI

Bradley Russell Wilson, FNP

  • Family Nurse Practitioner
  • Detroit, MI
National Provider Identifier
1508339987
Registry record updated Jan 8, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Nurse PractitionerTaxonomy code 363LF0000X
License
470429662 Issued in MI
Practice address
22101 Moross Rd
Detroit, MI 48236-2148
Phone
(313) 343-3660
NPI assigned
Jan 8, 2019
Sex
Male
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Jan 8, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Nurse Practitioner 363LF0000X 470429662 MI Primary

Addresses

Primary practice location

22101 Moross Rd
Detroit, MI 48236-2148

Mailing address

36251 Alfred St
New Baltimore, MI 48047-2106
Phone (586) 840-6016

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20231223000072 MI Practitioner - Nurse Practitioner 6305296864 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Nurse Practitioner
Education
Other, 2018
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices

Practice addresses (Care Compare)

18303 E 10 Mile Rd
500 St John Center for Wellness and Family Me
Roseville, MI 48066-4992
Phone (586) 498-5160

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Nurse Practitioner

State licenses

LicenseStateTypeSpecialty
470429662MIMDFamily Nurse Practitioner

Practice roles

OrganizationSpecialtyStatusNew patients
Henry Ford Health St. John Hospital CurrentSince Dec 6, 2023 Accepting new patients
Henry Ford Health St. John Hospital Current Accepting new patients
Henry Ford Health St. John Hospital CurrentSince Dec 6, 2023 Accepting new patients
Henry Ford Cornerstone Medical Group Current Accepting new patients
St. John Hospital Past Accepting new patients

Locations

42645 Garfield Rd
Ste 103
Clinton Twp, MI 48038
Phone (586) 286-0050

22101 Moross Rd
Detroit, MI 48236
Phone (313) 343-3248

46591 Romeo Plank Rd
Macomb, MI 48044
Phone (586) 226-6269

18303 E 10 Mile Rd
Ste 500
Roseville, MI 48066
Phone (586) 498-5160

Interoperability endpoints

  • Direct secure messaging: bwilson1157845@direct.hfhs.org
  • FHIR API: https://fhir-myrecord.cerner.com/r4/mQjCqHb5rkr1u1foU4dqhQPBpi7Qk9R4/

Organizations & group practices 5

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 8

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1546905600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1546905600000",
    "number": "1508339987",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "36251 ALFRED ST",
            "city": "NEW BALTIMORE",
            "state": "MI",
            "postal_code": "480472106",
            "telephone_number": "586-840-6016"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "22101 MOROSS RD",
            "city": "DETROIT",
            "state": "MI",
            "postal_code": "482362148",
            "telephone_number": "313-343-3660"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WILSON",
        "first_name": "BRADLEY",
        "middle_name": "RUSSELL",
        "credential": "FNP",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2019-01-08",
        "last_updated": "2019-01-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "MI",
            "license": "470429662",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Detroit, MI

Sources for this page

Verify at the official NPI Registry.