Healthcare Provider Details

I. General information

NPI: 1245630961
Provider Name (Legal Business Name): AMY Y. WANG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2014
Last Update Date: 04/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 N LAKE SHORE DR 11TH FLOOR
CHICAGO IL
60611-3152
US

IV. Provider business mailing address

750 N LAKE SHORE DR 11TH FLOOR
CHICAGO IL
60611-3152
US

V. Phone/Fax

Practice location:
  • Phone: 312-503-3229
  • Fax:
Mailing address:
  • Phone: 312-503-3229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036099027
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2083C0008X
TaxonomyClinical Informatics Physician
License Number036099027
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: