Provider Demographics
NPI:1376502138
Name:WILSON, RALPH STANLEY (MD)
Entity Type:Individual
Prefix:
First Name:RALPH
Middle Name:STANLEY
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 PROFESSIONAL BLVD
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47714-8009
Mailing Address - Country:US
Mailing Address - Phone:812-473-2060
Mailing Address - Fax:812-473-0763
Practice Address - Street 1:1020 PROFESSIONAL BLVD
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-8009
Practice Address - Country:US
Practice Address - Phone:812-473-2060
Practice Address - Fax:812-473-0763
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01022390207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000383763OtherANTHEM
IN113544OtherHEALTH ALLIANCE
INP00280947OtherRR MEDICARE
KY00000383763OtherANTHEM
IN113394OtherHEALTHLINK
IN637090RMedicare ID - Type Unspecified
IN000000383763OtherANTHEM