Provider Demographics
NPI:1730503657
Name:WILSON, THOMAS (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 E MASON ST STE 4P57
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62701-1034
Mailing Address - Country:US
Mailing Address - Phone:217-788-0706
Mailing Address - Fax:
Practice Address - Street 1:201 ANAMARIA DR
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7305
Practice Address - Country:US
Practice Address - Phone:605-503-8192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-12
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI64846-20207R00000X
IL036166996207RC0000X, 207RI0011X
MT1140094207RI0011X
SD15475207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100060365Medicaid