Individual
BRADLEY A WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
PO BOX 372, MATTOON, IL 61938-0372
(217) 258-2582
Mailing address
PO BOX 372, MATTOON, IL 61938-0372
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
2005016227
MO
208600000X
Surgery Physician
Primary
36118588
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
207215500
—
MO
01
—
207988
MEDICARE GRP NUMBER
IL
01
—
208959
MEDICARE GRP NUMBER
IL
01
—
718653
HEALTHLINK
MO
01
—
7470693
AETNA
MO
01
—
CE9335
RR GROUP
IL
01
—
I37919
MERCY HEALTH PLANS
MO
01
—
P00396925
RR MEDICARE NUMBER
IL
Enumeration date
01/04/2006
Last updated
03/05/2025
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