Provider Demographics
NPI:1528009768
Name:WILSON, KEITH M (MD)
Entity Type:Individual
Prefix:PROF
First Name:KEITH
Middle Name:M
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 636256 CENTRAL CREDENTIALING
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6256
Mailing Address - Country:US
Mailing Address - Phone:513-585-5507
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:222 PIEDMONT AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-4231
Practice Address - Country:US
Practice Address - Phone:513-475-8400
Practice Address - Fax:513-475-8228
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2017-12-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OH35062146207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1528009768OtherRAILROAD MEDICARE
OH1528009768OtherRAILROAD MEDICARE
OHWI0720342Medicare PIN
OH040007664Medicare PIN
OHWI0720343Medicare PIN