Basic Information
| Provider Information | |||||||||
| NPI: | 1245325794 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18 BRIDGE STREET | ||||||||
| Address2: | |||||||||
| City: | BAR HARBOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2072885082 | ||||||||
| FaxNumber: | 2072887024 | ||||||||
| Practice Location | |||||||||
| Address1: | DOROTHEA DIX AGENCY | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079440733 | ||||||||
| FaxNumber: | 2072883151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 07/09/2019 | ||||||||
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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 | 2084P0800X | MD7254 | ME | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084A0401X | 007254 | ME | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine |
ID Information
| ID | Type | State | Issuer | Description | 010211483 | 05 | ME | MEDICAID |