Provider Demographics
NPI:1528046141
Name:WILSON, BRADLEY A (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
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 1:1005 HEALTH CENTER DR STE 201
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-4693
Mailing Address - Country:US
Mailing Address - Phone:217-238-6055
Mailing Address - Fax:217-258-2216
Practice Address - Street 1:1000 HEALTH CENTER DR STE 101
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-4644
Practice Address - Country:US
Practice Address - Phone:217-258-4020
Practice Address - Fax:217-258-4023
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005016227208600000X
IL36118588208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208959OtherMEDICARE GRP NUMBER
MO207215500Medicaid
IL207988OtherMEDICARE GRP NUMBER
ILCE9335OtherRR GROUP
ILP00396925OtherRR MEDICARE NUMBER
MO718653OtherHEALTHLINK
MO7470693OtherAETNA
MOI37919OtherMERCY HEALTH PLANS
IL208959OtherMEDICARE GRP NUMBER
ILCE9335OtherRR GROUP
MO718653OtherHEALTHLINK