MEDICARE: BERNICE WILSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	32001561A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	32001561A	OTHER	IN	COTA

General Provider Information

NPI Number	:	1649458662
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BERNICE WILSON

Provider Business Mailing Address
First Line	:	4202 BUELL DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46807-2743
Country	:	US
Telephone Number	:	260-341-4756
Fax Number	:

Provider Business Practice Location Address
First Line	:	4202 BUELL DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46807-2743
Country	:	US
Telephone Number	:	260-341-4756
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/31/2008
Last Update Date	:	01/31/2008

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