Provider Demographics
NPI:1467672964
Name:WILSON, SYDNEY A (MD)
Entity Type:Individual
Prefix:
First Name:SYDNEY
Middle Name:A
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 N CAPITOL AVE
Practice Address - Street 2:NOYES PAVILION E-140
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1218
Practice Address - Country:US
Practice Address - Phone:317-962-8776
Practice Address - Fax:317-963-5285
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01063657A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200864930Medicaid
INP00920825OtherRAILROAD MEDICARE PTAN-CRITICAL CARE
IN200864930Medicaid
IN165460B4Medicare PIN
IN267030IIIMedicare PIN
INP00412079Medicare PIN