Healthcare Provider Details

I. General information

NPI: 1386694792
Provider Name (Legal Business Name): MR. JOHN ANTHONY WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 W 115TH ST
CHICAGO IL
60628-5512
US

IV. Provider business mailing address

9022 S COLFAX AVE
CHICAGO IL
60617-4025
US

V. Phone/Fax

Practice location:
  • Phone: 773-995-0638
  • Fax:
Mailing address:
  • Phone: 773-995-7858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberW42546178287
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: