Healthcare Provider Details

I. General information

NPI: 1548216195
Provider Name (Legal Business Name): RAYMOND B. WYNN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 08/07/2020
Certification Date: 08/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 WEST 12TH STREET UPMC REGIONAL CANCER CENTER
ERIE PA
16505
US

IV. Provider business mailing address

125 OAK RIDGE DR E
BURR RIDGE IL
60527-6869
US

V. Phone/Fax

Practice location:
  • Phone: 708-635-9133
  • Fax:
Mailing address:
  • Phone: 87-635-9133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberMD438611
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number036142602
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: