Basic Information
| Provider Information | |||||||||
| NPI: | 1710949581 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | MELINDA | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1126 S 70TH ST | ||||||||
| Address2: | SUITE N500 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532143151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144554780 | ||||||||
| FaxNumber: | 4144752936 | ||||||||
| Practice Location | |||||||||
| Address1: | 311 STRAIGHT ST | ||||||||
| Address2: | RADIOLOGY DEPARTMENT | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135592260 | ||||||||
| FaxNumber: | 5134755258 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2006 | ||||||||
| LastUpdateDate: | 05/27/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 35064665W | OH | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0917048 | 05 | OH | MEDICAID | 64932288 | 05 | KY | MEDICAID | 100386530 | 05 | IN | MEDICAID | WI0736415 | 01 | PTAN | OTHER |