Provider Demographics
NPI:1336328723
Name:T. PAUL WILDER, M.D.
Entity Type:Organization
Organization Name:T. PAUL WILDER, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:STONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-827-8662
Mailing Address - Street 1:319 8TH ST
Mailing Address - Street 2:STE 4
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42420-2963
Mailing Address - Country:US
Mailing Address - Phone:270-827-8662
Mailing Address - Fax:270-826-8220
Practice Address - Street 1:319 8TH ST
Practice Address - Street 2:STE 4
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-2963
Practice Address - Country:US
Practice Address - Phone:270-827-8662
Practice Address - Fax:270-826-8220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-01
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY15950207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000612983OtherANTHEM BLUE SHIELD
KY64159502Medicaid
KY00983001Medicare PIN
KY3107Medicare PIN
KYD32277Medicare UPIN