Provider Demographics
NPI:1336249127
Name:WILSON ENT PSC
Entity type:Organization
Organization Name:WILSON ENT PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESEIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-651-2433
Mailing Address - Street 1:PO BOX 1088
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42142-1088
Mailing Address - Country:US
Mailing Address - Phone:270-651-2433
Mailing Address - Fax:270-651-2949
Practice Address - Street 1:102 C PHYSICIANS BLVD
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141
Practice Address - Country:US
Practice Address - Phone:270-651-2433
Practice Address - Fax:270-651-2949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34426207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65932428Medicaid
KYDN6242OtherRAILROAD MEDICARE
KY000000065313OtherANTHEM ID
KY000000065313OtherANTHEM ID