Basic Information
| Provider Information | |||||||||
| NPI: | 1053301416 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILHELM | ||||||||
| FirstName: | KENNETH | ||||||||
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| NameSuffix: | JR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 217 W GEORGIA AVE | ||||||||
| Address2: | SUITE 115 | ||||||||
| City: | NAMPA | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836866811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084633000 | ||||||||
| FaxNumber: | 2084633034 | ||||||||
| Practice Location | |||||||||
| Address1: | 4400 E FLAMINGO AVE | ||||||||
| Address2: | |||||||||
| City: | NAMPA | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836879203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082884970 | ||||||||
| FaxNumber: | 2082884990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | M9346 | ID | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 75721 | 01 | ID | BLUE CROSS | OTHER | 000010151677 | 01 | ID | BLUE SHEILD | OTHER |