Basic Information
| Provider Information | |||||||||
| NPI: | 1346457934 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILBER | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | J | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 65 AIRPORT PKWY STE 114 | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461431439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178070268 | ||||||||
| FaxNumber: | 3175288115 | ||||||||
| Practice Location | |||||||||
| Address1: | 65 AIRPORT PKWY STE 114 | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461431439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178070268 | ||||||||
| FaxNumber: | 3175288115 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2007 | ||||||||
| LastUpdateDate: | 07/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 01065140A | IN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200916960 | 05 | IN | MEDICAID |