Provider Demographics
NPI:1629014717
Name:WILMOT, MICHAEL D
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:WILMOT
Suffix:
Gender:M
Credentials:
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 4460
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68104
Mailing Address - Country:US
Mailing Address - Phone:866-491-5807
Mailing Address - Fax:913-491-0411
Practice Address - Street 1:7500 MERCY RD
Practice Address - Street 2:ALEGENT BERGAN MERCY DEPT OF RADIOLOGY
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-2319
Practice Address - Country:US
Practice Address - Phone:402-398-5890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE135242085R0202X
IA212412085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA6973347Medicaid
IA7973347Medicaid
1600518OtherUHC SHARE ALLIANCE
IA5973347Medicaid
1042OtherMIDLANDS
IA8973347Medicaid
BW6851326OtherIA CONTROLLED SUBSTANCE
NE01572OtherBCBS
IA2973347Medicaid
IA19055OtherBCBS
1600004OtherUHC SHARE ALLIANCE
1600004OtherUHC SHARE ALLIANCE
NE088364Medicare PIN
NE01572OtherBCBS
1600004OtherUHC SHARE ALLIANCE
IA8973347Medicaid
NENA1355010Medicare PIN
BW6851326OtherIA CONTROLLED SUBSTANCE
D09056Medicare UPIN