Provider Demographics
NPI:1164577367
Name:DR BRADLEY C WILSON INC
Entity Type:Organization
Organization Name:DR BRADLEY C WILSON INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:C
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:740-342-3540
Mailing Address - Street 1:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-0550
Mailing Address - Country:US
Mailing Address - Phone:740-687-5164
Mailing Address - Fax:740-654-1417
Practice Address - Street 1:7756 ST RT 37 EAST
Practice Address - Street 2:
Practice Address - City:NEW LEXINGTON
Practice Address - State:OH
Practice Address - Zip Code:43764
Practice Address - Country:US
Practice Address - Phone:740-342-3540
Practice Address - Fax:740-342-3879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34004144207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2973215Medicaid
OH0737224Medicare PIN
OH2973215Medicaid