Basic Information
| Provider Information | |||||||||
| NPI: | 1255340337 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8035 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672080035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166899135 | ||||||||
| FaxNumber: | 3166899102 | ||||||||
| Practice Location | |||||||||
| Address1: | 612 N ANDOVER RD | ||||||||
| Address2: | |||||||||
| City: | ANDOVER | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670029778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3167336618 | ||||||||
| FaxNumber: | 3167335299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2006 | ||||||||
| LastUpdateDate: | 07/16/2007 | ||||||||
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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 | 207Q00000X | 25289 | KS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2807 | 01 | KS | PHS | OTHER | 041801 | 01 | KS | BCBS | OTHER | 100842 | 01 | KS | HPK | OTHER | 16949 | 01 | KS | COVENTRY | OTHER | 11084898 | 01 | KS | MULTIPLAN | OTHER |