Healthcare Provider Details

I. General information

NPI: 1255692794
Provider Name (Legal Business Name): MELISSA LYNNE WAGNER-SCHUMAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2012
Last Update Date: 02/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

912 S WOOD ST
CHICAGO IL
60612-4300
US

IV. Provider business mailing address

912 S WOOD ST
CHICAGO IL
60612-4300
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-0123
  • Fax:
Mailing address:
  • Phone: 312-996-0123
  • Fax: 312-413-1228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036.144446
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number35.129457
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number35.129457
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number036.144446
License Number StateIL
# 5
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036.144446
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: