Healthcare Provider Details

I. General information

NPI: 1891512745
Provider Name (Legal Business Name): ROGER WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2024
Last Update Date: 11/04/2025
Certification Date: 11/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22225 PAXTON AVE
SAUK VILLAGE IL
60411-5039
US

IV. Provider business mailing address

22225 PAXTON AVE
SAUK VILLAGE IL
60411-5039
US

V. Phone/Fax

Practice location:
  • Phone: 773-382-6558
  • Fax:
Mailing address:
  • Phone: 773-382-6558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: