Healthcare Provider Details

I. General information

NPI: 1972590362
Provider Name (Legal Business Name): KAN Y WU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 04/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

907 WEST LINCOLN AVE
CHARLESTON IL
61920-2413
US

IV. Provider business mailing address

PO BOX 770 907 WEST LINCOLN AVE
CHARLESTON IL
61920-2413
US

V. Phone/Fax

Practice location:
  • Phone: 217-345-2500
  • Fax: 217-345-8366
Mailing address:
  • Phone: 217-345-2500
  • Fax: 217-345-8366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036113712
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number18855
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: