MEDICARE: DR. JANE ELLEN WILSON MD

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	2080A0000X	Pediatric Adolescent Medicine Physician	01047151	IN
2	208000000X	Pediatrics Physician	01047151A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000507395	OTHER	IN	ANTHEM
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1659375335
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JANE ELLEN WILSON MD

Provider Business Mailing Address
First Line	:	250 N SHADELAND AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46219-4959
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5550 S EAST ST
Second Line	:	STE.I
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46227-1979
Country	:	US
Telephone Number	:	317-780-4080
Fax Number	:	317-780-4088

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

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	02/02/2022

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