Basic Information
Provider Information | |||||||||
NPI: | 1528046141 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILSON | ||||||||
FirstName: | BRADLEY | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1005 HEALTH CENTER DR STE 201 | ||||||||
Address2: |   | ||||||||
City: | MATTOON | ||||||||
State: | IL | ||||||||
PostalCode: | 619384693 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2172386055 | ||||||||
FaxNumber: | 2172582216 | ||||||||
Practice Location | |||||||||
Address1: | 1000 HEALTH CENTER DR STE 101 | ||||||||
Address2: |   | ||||||||
City: | MATTOON | ||||||||
State: | IL | ||||||||
PostalCode: | 619384644 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2172584020 | ||||||||
FaxNumber: | 2172584023 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/04/2006 | ||||||||
LastUpdateDate: | 04/15/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/15/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 2005016227 | MO | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 208600000X | 36118588 | IL | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 208959 | 01 | IL | MEDICARE GRP NUMBER | OTHER | 207215500 | 05 | MO |   | MEDICAID | 207988 | 01 | IL | MEDICARE GRP NUMBER | OTHER | CE9335 | 01 | IL | RR GROUP | OTHER | P00396925 | 01 | IL | RR MEDICARE NUMBER | OTHER | 718653 | 01 | MO | HEALTHLINK | OTHER | 7470693 | 01 | MO | AETNA | OTHER | I37919 | 01 | MO | MERCY HEALTH PLANS | OTHER |