Basic Information
| Provider Information | |||||||||
| NPI: | 1003841024 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 145 | ||||||||
| Address2: | RADIOLOGY ASSOCIATES OF MURRAY | ||||||||
| City: | MURARY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420710145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707591805 | ||||||||
| FaxNumber: | 8592232732 | ||||||||
| Practice Location | |||||||||
| Address1: | 803 POPLAR ST | ||||||||
| Address2: | MURRAY-CALLOWAY COUNTY HOSPITAL | ||||||||
| City: | MURRAY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707591805 | ||||||||
| FaxNumber: | 8592232732 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 16815 | KY | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 64168156 | 05 | KY | MEDICAID |