Healthcare Provider Details

I. General information

NPI: 1497921431
Provider Name (Legal Business Name): SUSAN WALTER WILSON, MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2008
Last Update Date: 01/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9899 E 126TH ST
FISHERS IN
46038-2821
US

IV. Provider business mailing address

PO BOX 3041
INDIANAPOLIS IN
46206-3041
US

V. Phone/Fax

Practice location:
  • Phone: 317-567-2180
  • Fax: 317-567-2191
Mailing address:
  • Phone: 317-614-9641
  • Fax: 317-713-1261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number StateIN

VIII. Authorized Official

Name: SUSAN WALTER WILSON
Title or Position: OWNER
Credential: MD
Phone: 317-567-2180