1255323630 NPI number — MR. STEPHEN WESLEY WILSON CRNA

Table of content: MR. STEPHEN WESLEY WILSON CRNA (NPI 1255323630)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255323630 NPI number — MR. STEPHEN WESLEY WILSON CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
STEPHEN
Provider Middle Name:
WESLEY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1255323630
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/05/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3101 MORNINGSIDE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALDWIN
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21013-9528
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-557-6724
Provider Business Mailing Address Fax Number:
410-557-4355

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10751 FALLS RD
Provider Second Line Business Practice Location Address:
SUITE 425
Provider Business Practice Location Address City Name:
LUTHERVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21093-4517
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-583-2760
Provider Business Practice Location Address Fax Number:
410-583-2759
Provider Enumeration Date:
08/22/2005

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: 367500000X , with the licence number:  R063574 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: KCE3GL . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: S4320001 . This is a "FEDERAL CAREFIRST" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00012294 . This is a "MEDICARE RAILROAD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 876R . This is a "MEDICARE" identifier . This identifiers is of the category "OTHER".




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