Basic Information
| Provider Information | |||||||||
| NPI: | 1083654198 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILDER | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | BRENT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3881 E SMITH RD | ||||||||
| Address2: | |||||||||
| City: | MEDINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442568771 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 18697 BAGLEY RD | ||||||||
| Address2: | |||||||||
| City: | MIDDLEBURG HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441303417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408168000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 05/27/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 35042804W | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0427710 | 05 | OH | MEDICAID | 942460636082 | 01 | OH | CARESOURCE | OTHER | P00221626 | 01 | OH | MEDICARE RR-GA | OTHER |