Healthcare Provider Details

I. General information

NPI: 1548383656
Provider Name (Legal Business Name): SHIHTIEN WANG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TIENTIEN WANG

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 09/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 W TAYLOR ST STE 2E
CHICAGO IL
60612-4795
US

IV. Provider business mailing address

840 S WOOD ST # MC856
CHICAGO IL
60612-4325
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-9291
  • Fax: 312-355-1473
Mailing address:
  • Phone: 312-996-9291
  • Fax: 312-355-1473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number036-127871
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: