Basic Information
Provider Information | |||||||||
NPI: | 1770564148 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILCOX | ||||||||
FirstName: | DENNIS | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 23625 COMMERCE PARK | ||||||||
Address2: | SUITE 204 | ||||||||
City: | BEACHWOOD | ||||||||
State: | OH | ||||||||
PostalCode: | 44122 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2162555701 | ||||||||
FaxNumber: | 2162555701 | ||||||||
Practice Location | |||||||||
Address1: | 3904 W 125TH TERRACE | ||||||||
Address2: |   | ||||||||
City: | LEAWOOD | ||||||||
State: | KS | ||||||||
PostalCode: | 662092643 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2162555700 | ||||||||
FaxNumber: | 2162555701 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/10/2005 | ||||||||
LastUpdateDate: | 12/05/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 28051 | KS | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 300134281 | 01 | KS | RXR MEDICARE | OTHER | 34195845104 | 05 | NE |   | MEDICAID | 341958451004 | 01 |   | TRICARE WEST | OTHER | 73381701 | 05 | AZ |   | MEDICAID | 341958451010 | 01 | OH | MEDICAL MUTUAL | OTHER | 12705151 | 01 | KS | BCBS | OTHER | 200002820A | 05 | KS |   | MEDICAID | 2345457 | 05 | OH |   | MEDICAID | 6409641500 | 05 | KY |   | MEDICAID | 806480700 | 05 | ID |   | MEDICAID | 1017159110001 | 05 | PA |   | MEDICAID |