NPIMap

Individual provider Active NPI

Kelby Jon Wilson, MD

  • Family Medicine Physician
  • Grangeville, ID
National Provider Identifier
1164872115
Registry record updated Sep 30, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
M-14749 Issued in ID
Practice address
607 W Main St
Grangeville, ID 83530-1345
Phone
(208) 983-1700
Fax
(208) 983-4665
NPI assigned
Jun 20, 2016
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Sep 30, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X M-14749 ID Primary

Addresses

Primary practice location

607 W Main St
Grangeville, ID 83530-1345

Mailing address

607 W Main St
Grangeville, ID 83530-1345
Phone (208) 983-1700

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address kelbywilson@syringahospital.cernerdirectcom Direct

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ID
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20190729001812 ID Practitioner - Family Practice 7416283460 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
University of Nevada School of Medicine, 2016
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Syringa General Hospital District C I FGroup PAC ID 6800707530, 19 clinicians

Practice addresses (Care Compare)

607 W Main St
Grangeville, ID 83530-1345
Phone (208) 983-1700

Hospital & facility affiliations

  • Syringa General Hospital Hospice Hospice, Grangeville, ID, CCN 131534
  • Syringa General Hospital Hospital, Grangeville, ID, CCN 131315
  • St Joseph Regional Medical Center Hospital, Lewiston, ID, CCN 130003
  • St Mary'S Hospital Hospital, Cottonwood, ID, CCN 131321
  • Tri-State Memorial Hospital Hospital, Clarkston, WA, CCN 501332

Merit-based Incentive Payment System (MIPS)

Final score
93.78 of 100Reported as apm
Quality
80.38
Promoting interoperability
100
Improvement activities
40

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
M-14749IDMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Syringa General Hospital District C I F CurrentSince Jul 31, 2019 Accepting new patients
Syringa General Hospital District C I F CurrentSince Jul 31, 2019 Accepting new patients

Locations

607 W Main St
Grangeville, ID 83530
Phone (208) 983-1700

Interoperability endpoints

  • Direct secure messaging: kwilson627439@wm.providencedirect.org

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 and National Provider Directory roles.

Hospital & facility affiliations 12

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1466380800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1601424000000",
    "number": "1164872115",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "607 W MAIN ST",
            "city": "GRANGEVILLE",
            "state": "ID",
            "postal_code": "835301345",
            "telephone_number": "208-983-1700",
            "fax_number": "208-983-4665"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "607 W MAIN ST",
            "city": "GRANGEVILLE",
            "state": "ID",
            "postal_code": "835301345",
            "telephone_number": "208-983-1700",
            "fax_number": "208-983-4665"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WILSON",
        "first_name": "KELBY",
        "middle_name": "JON",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2016-06-20",
        "last_updated": "2020-09-30",
        "certification_date": "2020-09-30",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "ID",
            "license": "M-14749",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "kelbywilson@syringahospital.cernerdirectcom",
            "affiliation": "N",
            "endpointDescription": "Syringa Hospital",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "CCDA",
            "address_1": "607 W Main St",
            "city": "Grangeville",
            "state": "ID",
            "country_code": "US",
            "postal_code": "835301345",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Grangeville, ID

Sources for this page

Verify at the official NPI Registry.