Healthcare Provider Details

I. General information

NPI: 1811155278
Provider Name (Legal Business Name): MARYLOUISE KIYANA WILKERSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2008
Last Update Date: 01/31/2022
Certification Date: 01/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 W HARRISON ST
CHICAGO IL
60612-3801
US

IV. Provider business mailing address

1620 W HARRISON ST
CHICAGO IL
60612-3801
US

V. Phone/Fax

Practice location:
  • Phone: 312-947-8800
  • Fax:
Mailing address:
  • Phone: 312-947-8800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number036126183
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: