Basic Information
| Provider Information | |||||||||
| NPI: | 1861463861 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | LINDA | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CASSEL | ||||||||
| OtherFirstName: | LINDA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 25317 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336225317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132860033 | ||||||||
| FaxNumber: | 8132821806 | ||||||||
| Practice Location | |||||||||
| Address1: | 116 PARSONS PARK DR | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335116066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136816625 | ||||||||
| FaxNumber: | 8136846043 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2006 | ||||||||
| LastUpdateDate: | 10/13/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | ME118638 | FL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | MD026147E | PA | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 012103000 | 05 | FL | MEDICAID | 000866973 | 05 | PA | MEDICAID | 232359401 | 01 | PA | MAIN LINE HEALTHCARE | OTHER |