Provider Demographics
NPI:1184735730
Name:KATHRYN A. S. WILSON DO LLC
Entity type:Organization
Organization Name:KATHRYN A. S. WILSON DO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:937-748-9051
Mailing Address - Street 1:70 SOUTHFIELD CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-9268
Mailing Address - Country:US
Mailing Address - Phone:800-357-5728
Mailing Address - Fax:937-291-2962
Practice Address - Street 1:32 S RICHARDS RUN
Practice Address - Street 2:
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066-8003
Practice Address - Country:US
Practice Address - Phone:937-748-9051
Practice Address - Fax:937-748-9054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2346572Medicaid
OHCK6330OtherRAILROAD MEDICARE
OH150287OtherUNITED MINE WORKERS
OH=========-00OtherBWC
OH9321571Medicare ID - Type UnspecifiedGROUP NUMBER