Healthcare Provider Details

I. General information

NPI: 1225511611
Provider Name (Legal Business Name): ANDI WANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2018
Last Update Date: 06/02/2024
Certification Date: 06/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 E CHESTNUT ST APT 2005
CHICAGO IL
60611-2457
US

IV. Provider business mailing address

1740 W TAYLOR ST
CHICAGO IL
60612-7232
US

V. Phone/Fax

Practice location:
  • Phone: 216-213-8743
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code202C00000X
TaxonomyIndependent Medical Examiner Physician
License NumberTRN36059
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125080158
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: