Provider Demographics
NPI:1861575557
Name:WILSON, CHAD J (PT)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:J
Last Name:WILSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7759 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-6742
Mailing Address - Country:US
Mailing Address - Phone:317-359-1215
Mailing Address - Fax:317-359-1235
Practice Address - Street 1:7035 W 96TH STREET # D
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:76250-3303
Practice Address - Country:US
Practice Address - Phone:317-284-0505
Practice Address - Fax:317-284-0507
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05008759A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000384246OtherANTHEM
318840PMedicare ID - Type Unspecified