1649287400 NPI number — DR. ROY A WILSON

Table of content: DR. ROY A WILSON (NPI 1649287400)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649287400 NPI number — DR. ROY A WILSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
ROY
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
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:
1649287400
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31114 HAGGERTY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMINGTON HILLS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48331-5803
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-788-1610
Provider Business Mailing Address Fax Number:
248-788-8290

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
31114 HAGGERTY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARMINGTON HILLS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48331-5803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-788-1610
Provider Business Practice Location Address Fax Number:
248-788-8290
Provider Enumeration Date:
08/02/2006

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: 152W00000X , with the licence number:  49010032126 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 459590394 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 900F31045 . This is a "HEALTH ALLIANCE PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 460850086 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 900F368040 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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