MEDICARE: DR. ROGER W WILSON D.C.

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	111N00000X	Chiropractor	1341	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	421248625003	OTHER	OH	MEDICAL MUTUAL OF OH
2	000000149032	OTHER	OH	ANTHEM BC & BS
3	1052235	OTHER	OH	AETNA
4	44-00336	OTHER	OH	UNITEDHEALTH CARE

General Provider Information

NPI Number	:	1851372775
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROGER W WILSON D.C.

Provider Business Mailing Address
First Line	:	200 PARK PL
Second Line	:
City	:	CHAGRIN FALLS
State	:	OH
Zip	:	44022-4456
Country	:	US
Telephone Number	:	440-247-5383
Fax Number	:	440-338-1839

Provider Business Practice Location Address
First Line	:	200 PARK PL
Second Line	:
City	:	CHAGRIN FALLS
State	:	OH
Zip	:	44022-4456
Country	:	US
Telephone Number	:	440-247-5383
Fax Number	:	440-338-1839

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

Provider Enumeration Date	:	11/08/2005
Last Update Date	:	07/08/2007

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