1093719726 NPI number — SUSAN KADY WILSON M.D.

Table of content: SUSAN KADY WILSON M.D. (NPI 1093719726)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093719726 NPI number — SUSAN KADY WILSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
SUSAN
Provider Middle Name:
KADY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1093719726
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1900 RANDOLPH RD
Provider Second Line Business Mailing Address:
SUITE 500
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28207-1122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-384-9113
Provider Business Mailing Address Fax Number:
704-316-0508

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14 DOCTORS CIR
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
SUPPLY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28462-4097
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-754-9166
Provider Business Practice Location Address Fax Number:
910-754-2972
Provider Enumeration Date:
06/10/2005

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: 207V00000X , with the licence number:  19107 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: T30464 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com