1528046141 NPI number — BRADLEY A WILSON MD

Table of content: BRADLEY A WILSON MD (NPI 1528046141)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528046141 NPI number — BRADLEY A WILSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
BRADLEY
Provider Middle Name:
A
Provider Name Prefix Text:
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:
1528046141
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1005 HEALTH CENTER DR STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MATTOON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61938-4693
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-238-6055
Provider Business Mailing Address Fax Number:
217-258-2216

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 HEALTH CENTER DR STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MATTOON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61938-4644
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-258-4020
Provider Business Practice Location Address Fax Number:
217-258-4023
Provider Enumeration Date:
01/04/2006

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: 208600000X , with the licence number:  2005016227 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 36118588 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 208959 . This is a "MEDICARE GRP NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 207215500 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 207988 . This is a "MEDICARE GRP NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CE9335 . This is a "RR GROUP" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P00396925 . This is a "RR MEDICARE NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 718653 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 7470693 . This is a "AETNA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: I37919 . This is a "MERCY HEALTH PLANS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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