Provider Demographics
NPI:1437126661
Name:WILSON, AUDREY R (MD)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:R
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:
Other - Last Name:RADOMSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:980 US HIGHWAY 9
Mailing Address - Street 2:
Mailing Address - City:SOUTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08879
Mailing Address - Country:US
Mailing Address - Phone:732-553-9729
Mailing Address - Fax:732-553-9730
Practice Address - Street 1:1815 COTTMAN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111
Practice Address - Country:US
Practice Address - Phone:215-742-5662
Practice Address - Fax:215-742-5663
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD029434L2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009479910015Medicaid
E70752Medicare UPIN
PA0009479910015Medicaid