1497771984 NPI number — DR. MICHAEL S WILSON II MD

Table of content: DR. MICHAEL S WILSON II MD (NPI 1497771984)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497771984 NPI number — DR. MICHAEL S WILSON II MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
MICHAEL
Provider Middle Name:
S
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
II
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:
WILSON
Provider Other First Name:
MICHAEL
Provider Other Middle Name:
S
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
JR.
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1497771984
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/08/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 636256 CENTRAL CREDENTIALING
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45263-6256
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-245-3107
Provider Business Mailing Address Fax Number:
513-585-5511

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
234 GOODMAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CINCINNATI
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45219-2364
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-584-8577
Provider Business Practice Location Address Fax Number:
513-584-5618
Provider Enumeration Date:
07/15/2006

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: 2084P0800X , with the licence number:  35 088361 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000533008 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000224457 . This is a "UNISON" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2683850 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 364139 . This is a "WELLCARE MEDICAID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 7339878 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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