Basic Information
| Provider Information | |||||||||
| NPI: | 1689697716 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILHELMUS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1221 S BROADWAY | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405042701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592584000 | ||||||||
| FaxNumber: | 8592584796 | ||||||||
| Practice Location | |||||||||
| Address1: | 1221 S BROADWAY | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405042701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592584000 | ||||||||
| FaxNumber: | 8592584796 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 11/02/2007 | ||||||||
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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 | 207ZC0500X | 19828 | KY | Y | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZP0102X | 19828 | KY | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 64198286 | 05 | KY | MEDICAID | CB5773 | 01 | GA | RR MEDICARE GRP | OTHER | 4000501 | 01 | KY | MEDICARE LAB GRP | OTHER | 37903705 | 01 | KY | MEDICAID LAB GRP | OTHER |