Provider Demographics
NPI:1376511063
Name:WILSON, RONALD L (MD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:L
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:PO BOX 734839
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-4839
Mailing Address - Country:US
Mailing Address - Phone:502-253-4900
Mailing Address - Fax:
Practice Address - Street 1:4620 VILLAGE SQUARE DRIVE
Practice Address - Street 2:SUITE 101
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?:Yes
Enumeration Date:2006-03-09
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22453207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000062924OtherBLUE CROSS ID NUMBER
KY64224538Medicaid
4929Medicare ID - Type UnspecifiedMEDICARE GROUP ID NUMBER
KY000000062924OtherBLUE CROSS ID NUMBER
KY64224538Medicaid
110112564Medicare PIN
1492901Medicare PIN