1245325794 NPI number — DR. ROGER M WILSON MD

Table of content: DR. ROGER M WILSON MD (NPI 1245325794)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245325794 NPI number — DR. ROGER M WILSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
ROGER
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
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:
1245325794
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18 BRIDGE STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAR HARBOR
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04609
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-288-5082
Provider Business Mailing Address Fax Number:
207-288-7024

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
DOROTHEA DIX AGENCY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BANGOR
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-944-0733
Provider Business Practice Location Address Fax Number:
207-288-3151
Provider Enumeration Date:
10/03/2006

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:  MD7254 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084A0401X , with the licence number: 007254 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 010211483 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com