MEDICARE: KEVIN WILSON PA-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	363AM0700X	Medical Physician Assistant	085-000488	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	085-000488	OTHER	IL	STATE LICENSE

General Provider Information

NPI Number	:	1063424984
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN WILSON PA-C

Provider Business Mailing Address
First Line	:	4500 MEMORIAL DRIVE
Second Line	:	MEMORIAL HOSPITAL CREDENTIALING DEPARTMENT
City	:	BELLEVILLE
State	:	IL
Zip	:	62226
Country	:	US
Telephone Number	:	618-257-4644
Fax Number	:	618-257-6946

Provider Business Practice Location Address
First Line	:	130 LINCOLN PLACE CT
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62221-5884
Country	:	US
Telephone Number	:	618-257-2029
Fax Number	:	618-235-5371

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

Provider Enumeration Date	:	08/12/2006
Last Update Date	:	03/21/2016

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