Healthcare Provider Details

I. General information

NPI: 1114013125
Provider Name (Legal Business Name): ANDREW C. WILBUR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 07/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 W. TAYLOR
CHICAGO IL
60612
US

IV. Provider business mailing address

1740 W TAYLOR ST 2483 UICH, MC 931
CHICAGO IL
60612-7232
US

V. Phone/Fax

Practice location:
  • Phone: 866-600-2273
  • Fax:
Mailing address:
  • Phone: 312-996-0234
  • Fax: 312-355-2098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036061253
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: