Active NPI
Kevin Wilson, PA-C
- Medical Physician Assistant
- Belleville, IL
National Provider Identifier
1063424984
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Medical Physician Assistant
- License
- 085-000488
- Practice address
- 130 Lincoln Place CT
Belleville, IL 62221-5884 - Phone
- (618) 257-2029
- Fax
- (618) 235-5371
- NPI assigned
- Aug 12, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Medical Physician Assistant | 363AM0700X | 085-000488 | IL | Primary |
Addresses
Primary practice location
130 Lincoln Place CT
Belleville, IL 62221-5884
Mailing address
4500 Memorial Drive
Memorial Hospital Credentialing Department
Belleville, IL 62226
Phone (618) 257-4644
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 085-000488 | Other | IL | STATE LICENSE |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 085-000488 | IL | MD | Medical Physician Assistant |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| PC Associates, LLC | Past | Accepting new patients | |
| Gibson Community Hospital Association | Past | Accepting new patients |
Interoperability endpoints
- kevin.wilson.1@14258.direct.athenahealth.com
- kevin.wilson.1@20777.direct.athenahealth.com
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
-
dba Gibson Area Hospital and Health Services
- Critical Access Hospital
- Gibson City, IL
- NPI 1114935681
-
- Family Medicine Physician
- Dupo, IL
- NPI 1437462637
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1155340800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1458518400000",
"number": "1063424984",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4500 MEMORIAL DRIVE",
"address_2": "MEMORIAL HOSPITAL CREDENTIALING DEPARTMENT",
"city": "BELLEVILLE",
"state": "IL",
"postal_code": "62226",
"telephone_number": "618-257-4644",
"fax_number": "618-257-6946"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "130 LINCOLN PLACE CT",
"city": "BELLEVILLE",
"state": "IL",
"postal_code": "622215884",
"telephone_number": "618-257-2029",
"fax_number": "618-235-5371"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WILSON",
"first_name": "KEVIN",
"credential": "PA-C",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-08-12",
"last_updated": "2016-03-21",
"status": "A"
},
"taxonomies": [
{
"code": "363AM0700X",
"taxonomy_group": "",
"desc": "Physician Assistant, Medical",
"state": "IL",
"license": "085-000488",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "STATE LICENSE",
"identifier": "085-000488",
"state": "IL"
}
],
"endpoints": [],
"other_names": []
}Other providers in Belleville, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 21, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.