Healthcare Provider Details

I. General information

NPI: 1376237453
Provider Name (Legal Business Name): STEVEN ANTHONY WILSON JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2023
Last Update Date: 06/02/2023
Certification Date: 06/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1969 W OGDEN AVE
CHICAGO IL
60612-3765
US

IV. Provider business mailing address

1969 W OGDEN AVE
CHICAGO IL
60612-3765
US

V. Phone/Fax

Practice location:
  • Phone: 312-572-2643
  • Fax:
Mailing address:
  • Phone: 312-572-2643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125.082298
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: