Basic Information
| Provider Information | |||||||||
| NPI: | 1457343063 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 12TH AVE N | ||||||||
| Address2: | SUITE 140W | ||||||||
| City: | BILLINGS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 591017506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062386540 | ||||||||
| FaxNumber: | 4062386599 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 12TH AVE N | ||||||||
| Address2: | SUITE 140W | ||||||||
| City: | BILLINGS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 591017506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062386540 | ||||||||
| FaxNumber: | 4062386599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2005 | ||||||||
| LastUpdateDate: | 04/29/2008 | ||||||||
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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 | 207X00000X | 8411 | MT | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 000091778 | 01 | MT | BLUECROSS BLUESHIELD | OTHER | 108160 | 05 | MT | MEDICAID | 114452900 | 05 | WY | MEDICAID | 200033018 | 01 | MT | RR MEDICARE | OTHER |