Provider Demographics
NPI:1033431507
Name:WILSONMEDICALASSOCIATESLLC
Entity Type:Organization
Organization Name:WILSONMEDICALASSOCIATESLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:EVERETT
Authorized Official - Middle Name:JAN
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:740-574-2220
Mailing Address - Street 1:1661 STATE ROUTE 522
Mailing Address - Street 2:UNIT #2
Mailing Address - City:WHEELERSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45694-8120
Mailing Address - Country:US
Mailing Address - Phone:740-574-2220
Mailing Address - Fax:740-574-2215
Practice Address - Street 1:1661 STATE ROUTE 522
Practice Address - Street 2:UNIT #2
Practice Address - City:WHEELERSBURG
Practice Address - State:OH
Practice Address - Zip Code:45694-8120
Practice Address - Country:US
Practice Address - Phone:740-574-2220
Practice Address - Fax:740-574-2215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-24
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-002236261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care