1437126661 NPI number — AUDREY R WILSON MD

Table of content: AUDREY R WILSON MD (NPI 1437126661)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437126661 NPI number — AUDREY R WILSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
AUDREY
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RADOMSKY
Provider Other First Name:
AUDREY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1437126661
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
980 US HIGHWAY 9
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH AMBOY
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08879
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-553-9729
Provider Business Mailing Address Fax Number:
732-553-9730

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1815 COTTMAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-742-5662
Provider Business Practice Location Address Fax Number:
215-742-5663
Provider Enumeration Date:
03/07/2006

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: 2085R0202X , with the licence number:  MD029434L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0009479910015 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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