Basic Information
| Provider Information | |||||||||
| NPI: | 1497921431 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUSAN WALTER WILSON, MD, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3041 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462063041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176149641 | ||||||||
| FaxNumber: | 3177131261 | ||||||||
| Practice Location | |||||||||
| Address1: | 9899 E 126TH ST | ||||||||
| Address2: | |||||||||
| City: | FISHERS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460382821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175672180 | ||||||||
| FaxNumber: | 3175672191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2008 | ||||||||
| LastUpdateDate: | 01/11/2010 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | WALTER | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3175672180 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | IN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 100237890 | 05 | IN | MEDICAID |