Provider Demographics
NPI:1487828547
Name:WILSON, KELVEY RICHARDS (MD)
Entity Type:Individual
Prefix:DR
First Name:KELVEY
Middle Name:RICHARDS
Last Name:WILSON
Suffix:
Gender:F
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:PO BOX 547
Mailing Address - Street 2:ATT: CVMC FINANCE DEPT
Mailing Address - City:BARRE
Mailing Address - State:VT
Mailing Address - Zip Code:05641-0547
Mailing Address - Country:US
Mailing Address - Phone:802-371-4263
Mailing Address - Fax:802-371-4481
Practice Address - Street 1:130 FISHER RD
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:VT
Practice Address - Zip Code:05602-9516
Practice Address - Country:US
Practice Address - Phone:802-371-4263
Practice Address - Fax:802-371-4481
Is Sole Proprietor?:No
Enumeration Date:2008-04-18
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VT042.0012164207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1019211Medicaid
VT002401601OtherMEDICARE PTAN LINKED TO CVMC