Healthcare Provider Details

I. General information

NPI: 1063100303
Provider Name (Legal Business Name): GERALD WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2023
Last Update Date: 04/25/2023
Certification Date: 04/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 N CLARK ST
CHICAGO IL
60610-2941
US

IV. Provider business mailing address

1004 N CLARK ST
CHICAGO IL
60610-2941
US

V. Phone/Fax

Practice location:
  • Phone: 312-291-9435
  • Fax:
Mailing address:
  • Phone: 312-291-9435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number011253222
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: