Basic Information
Provider Information | |||||||||
NPI: | 1548256498 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILSON | ||||||||
FirstName: | LORI | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 65 KANE ST | ||||||||
Address2: | PROVIDER ENROLLMENT | ||||||||
City: | WEST HARTFORD | ||||||||
State: | CT | ||||||||
PostalCode: | 061192110 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8605236421 | ||||||||
FaxNumber: | 8605233701 | ||||||||
Practice Location | |||||||||
Address1: | 263 FARMINGTON AVE, MC 1614 | ||||||||
Address2: | NEAG COMPREHENSIVE CANCER CENTER - SURG ONC | ||||||||
City: | FARMINGTON | ||||||||
State: | CT | ||||||||
PostalCode: | 060300001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8606796052 | ||||||||
FaxNumber: | 8606794973 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/26/2005 | ||||||||
LastUpdateDate: | 02/17/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 043799 | CT | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 1427997 | 05 | CT |   | MEDICAID |