Provider Demographics
NPI:1780735464
Name:WILEY, KIM STEVEN (MD)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:STEVEN
Last Name:WILEY
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 6493
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003
Mailing Address - Country:US
Mailing Address - Phone:304-238-0212
Mailing Address - Fax:304-238-0215
Practice Address - Street 1:76 16TH ST
Practice Address - Street 2:100
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-3660
Practice Address - Country:US
Practice Address - Phone:304-242-7106
Practice Address - Fax:304-242-7108
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35080502208C00000X
WV18684208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2289867Medicaid
WV1806640000Medicaid
OH2289867Medicaid
H47253Medicare UPIN
OH4059183Medicare ID - Type Unspecified