Provider Demographics
NPI:1881611697
Name:WILGER, MARY RUTH (DO)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:RUTH
Last Name:WILGER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10343 DAWSONS CREEK BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1906
Mailing Address - Country:US
Mailing Address - Phone:260-203-9600
Mailing Address - Fax:260-203-9602
Practice Address - Street 1:7950 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4140
Practice Address - Country:US
Practice Address - Phone:260-203-9600
Practice Address - Fax:260-203-9602
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002012207P00000X
IN02002012A208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200196750Medicaid
G81748Medicare UPIN
INM400073775Medicare PIN
IN200196750Medicaid
IN200196750Medicaid
IN138420RMedicare ID - Type Unspecified