Provider Demographics
NPI:1952508715
Name:WILSON, RICHARD SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:SCOTT
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:P O BOX 9100
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42002-9100
Mailing Address - Country:US
Mailing Address - Phone:270-442-8575
Mailing Address - Fax:270-442-8783
Practice Address - Street 1:4620 VILLAGE SQUARE DRIVE
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-7501
Practice Address - Country:US
Practice Address - Phone:270-442-8575
Practice Address - Fax:270-442-8783
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY41142207P00000X, 208M00000X, 207R00000X
MS654-L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100050700Medicaid
CB8326OtherRAILROAD MEDICARE GROUP
P00612564OtherRAILROAD MEDICARE INDIVIDUAL
KY7100050700Medicaid
KYK060582Medicare PIN