Provider Demographics
NPI:1245662410
Name:KENNETH M. WILSON, M.D., P.C.
Entity type:Organization
Organization Name:KENNETH M. WILSON, M.D., P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:MITCHELL
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-777-2255
Mailing Address - Street 1:PO BOX 1168
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:OR
Mailing Address - Zip Code:97013-1168
Mailing Address - Country:US
Mailing Address - Phone:936-777-2255
Mailing Address - Fax:503-375-3737
Practice Address - Street 1:700 BELLEVUE ST SE STE 260
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3888
Practice Address - Country:US
Practice Address - Phone:503-375-3636
Practice Address - Fax:503-375-3737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-30
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD16217174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR045336Medicaid
OR045336Medicaid
ORE79234Medicare UPIN
OR133332Medicare PIN