Individual Professional Information |
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NPI
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1780664664
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Unique healthcare provider (clinician) ID assigned by NPPES
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PECOS UID
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0345137907
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Unique individual clinician ID assigned by PECOS
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Professional Enrollment ID
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I20190318000838
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Unique ID for the individual professional enrollment that is the source for the data in the observation
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Provider Last Name
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WILSON
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Individual professional last name
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Provider First Name
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DUANE
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Individual professional first name
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Provider Middle Name
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CHARLES
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Individual professional middle name
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Provider Gender
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M
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The provider's gender if the provider is a person.
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Practice Information |
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Organization Legal Name
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TON SAN SIMON HEALTH CENTER
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Legal name of the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
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Group Practice PAC ID
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8123194354
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Unique Group Practice ID assigned by PECOS to the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
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Number of Group Practice members
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19
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Total number of individual professionals affiliated with the Group Practice based on Group Practice PAC ID
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Line 1 Street Address
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WEST HWY 86 MILE MARKER 74
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Group Practice or individual's line 1 address
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Line 2 Street Address
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SAN SIMON HEALTH CENTER
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Group Practice or individual's line 2 address
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City
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SELLS
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Group Practice or individual's city
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State
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AZ
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Group Practice or individual's state
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Zip Code
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856340000
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Group Practice or individual's zip code (9 digits when available)
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Phone Number
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5203627003
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Phone number is listed only when there is a single phone number available for the practice location address
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Hospital(s) Affiliation Information |
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Hospital Affiliation CCN 1
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330241
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Medicare CCN of hospital where individual professional provides service 1
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Hospital Affiliation LBN 1
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UNIVERSITY HOSPITAL S U N Y HEALTH SCIENCE CENTER
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Legal business name of hospital where individual professional provides service 1
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Hospital Affiliation CCN 2
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030071
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Medicare CCN of hospital where individual professional provides service 2
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Hospital Affiliation LBN 2
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FORT DEFIANCE INDIAN HOSPITAL
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Legal business name of hospital where individual professional provides service 2
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Hospital Affiliation CCN 3
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501303
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Medicare CCN of hospital where individual professional provides service 3
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Hospital Affiliation LBN 3
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WILLAPA HARBOR HOSPITAL
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Legal business name of hospital where individual professional provides service 3
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Hospital Affiliation CCN 4
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471306
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Medicare CCN of hospital where individual professional provides service 4
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Hospital Affiliation LBN 4
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SPRINGFIELD HOSPITAL
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Legal business name of hospital where individual professional provides service 4
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Hospital Affiliation CCN 5
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371321
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Medicare CCN of hospital where individual professional provides service 5
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Hospital Affiliation LBN 5
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HOLDENVILLE GENERAL HOSPITAL
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Legal business name of hospital where individual professional provides service 5
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Professional Accepts Medicare Assignment
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Y
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