1245291251 NPI number — MS. JODI ANDERSON WILSON NP

Table of content: MS. JODI ANDERSON WILSON NP (NPI 1245291251)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245291251 NPI number — MS. JODI ANDERSON WILSON NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
JODI
Provider Middle Name:
ANDERSON
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
REALE
Provider Other First Name:
JODI
Provider Other Middle Name:
ANDERSON
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1245291251
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 415348
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02241-5348
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55 LAKE AVE N
Provider Second Line Business Practice Location Address:
DEPARTMENT OF PULMONARY MEDICINE
Provider Business Practice Location Address City Name:
WORCESTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01655
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-856-1975
Provider Business Practice Location Address Fax Number:
508-334-7854
Provider Enumeration Date:
03/29/2006

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: 363L00000X , with the licence number:  180210 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2100X , with the licence number: RN180210 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 110016488A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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