Basic Information
| Provider Information | |||||||||
| NPI: | 1265566749 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAYSVILLE OBSTETRIC & GYNECOLOGIC ASSOCIATES PSC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MAYSVILLE OB-GYN | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 991 MEDICAL PARK DR | ||||||||
| Address2: | SUITE 309 | ||||||||
| City: | MAYSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410568764 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067595331 | ||||||||
| FaxNumber: | 6067595363 | ||||||||
| Practice Location | |||||||||
| Address1: | 991 MEDICAL PARK DR | ||||||||
| Address2: | SUITE 309 | ||||||||
| City: | MAYSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410568764 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067595331 | ||||||||
| FaxNumber: | 6067595363 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6067595331 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M. D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 0537100 | 05 | OH | MEDICAID | 65908980 | 05 | KY | MEDICAID |