Active NPI
Mary M Wilson, MD
- Emergency Medicine Physician
- Champlin, MN
National Provider Identifier
1992764054
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Emergency Medicine Physician
- License
- 33356
- Practice address
- 11665 Pondview CT
Champlin, MN 55316-2629 - Phone
- (763) 421-9387
- Fax
- (763) 421-9387
- NPI assigned
- Mar 18, 2006
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Emergency Medicine Physician | 207P00000X | 33356 | MN | Primary |
Addresses
Primary practice location
11665 Pondview CT
Champlin, MN 55316-2629
Mailing address
11665 Pondview CT
Champlin, MN 55316-2629
Phone (763) 421-9387
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 33356 | Other | MN MEDICAL LICENSE | |
| 938500200 | Medicaid | MN |
Other names 1
- Mrs. Mary Margaret Wilson
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: No
- Medical equipment: Yes
- Home health: No
- Power mobility devices: Yes
- Hospice: No
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1142640000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1289865600000",
"number": "1992764054",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "11665 PONDVIEW CT",
"city": "CHAMPLIN",
"state": "MN",
"postal_code": "553162629",
"telephone_number": "763-421-9387",
"fax_number": "763-421-9387"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "11665 PONDVIEW CT",
"city": "CHAMPLIN",
"state": "MN",
"postal_code": "553162629",
"telephone_number": "763-421-9387",
"fax_number": "763-421-9387"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WILSON",
"first_name": "MARY",
"middle_name": "M",
"name_prefix": "Dr.",
"credential": "MD",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2006-03-18",
"last_updated": "2010-11-16",
"status": "A"
},
"taxonomies": [
{
"code": "207P00000X",
"taxonomy_group": "",
"desc": "Emergency Medicine",
"state": "MN",
"license": "33356",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "MN MEDICAL LICENSE",
"identifier": "33356",
"state": null
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "938500200",
"state": "MN"
}
],
"endpoints": [],
"other_names": [
{
"first_name": "MARY",
"last_name": "WILSON",
"middle_name": "MARGARET",
"prefix": "MRS.",
"credential": "MD",
"code": "1",
"type": "Former Name"
}
]
}Other providers in Champlin, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 16, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.