Healthcare Provider Details

I. General information

NPI: 1942224076
Provider Name (Legal Business Name): ERIC C. WILSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 11/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 S BROADWAY
LEXINGTON KY
40504-2701
US

IV. Provider business mailing address

1221 S BROADWAY
LEXINGTON KY
40504-2701
US

V. Phone/Fax

Practice location:
  • Phone: 859-258-4000
  • Fax: 859-258-4796
Mailing address:
  • Phone: 859-258-4000
  • Fax: 859-258-4796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number17589
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License Number17589
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number17589
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: