Provider Demographics
NPI:1962623249
Name:R.L. WILSON, M.D., PC
Entity type:Organization
Organization Name:R.L. WILSON, M.D., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICKEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:574-233-5858
Mailing Address - Street 1:828 E COLFAX AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2804
Mailing Address - Country:US
Mailing Address - Phone:574-233-5858
Mailing Address - Fax:
Practice Address - Street 1:828 E COLFAX AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2804
Practice Address - Country:US
Practice Address - Phone:574-233-5858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
IN50003038A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN166500Medicare ID - Type Unspecified