Basic Information
| Provider Information | |||||||||
| NPI: | 1326033408 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3103 EXECUTIVE PKWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436061312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194744064 | ||||||||
| FaxNumber: | 4194722772 | ||||||||
| Practice Location | |||||||||
| Address1: | 2142 N COVE BLVD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436063895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192914000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2005 | ||||||||
| LastUpdateDate: | 01/17/2012 | ||||||||
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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 | 35-031930 | OH | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 300013461 | 01 | OH | RR MEDICARE | OTHER | 0350178 | 05 | OH | MEDICAID |