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General NPI Number Information
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NPI Number | 1134238934
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Entity Type | Organization
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Legal Business Name | WILCO FAMILY PRACTICE, LTD.
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Dates
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Enumeration Date | 08/29/2006
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Last Update Date | 03/25/2014
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Provider Practice Location Address
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Address Line | 2740 W FOSTER AVE SUITE 307
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City | CHICAGO
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State | IL
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Zip | 60625-3500
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Country | US
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Telephone | 872-208-7709
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Fax | 872-208-7703
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Provider Business Mailing Address
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Address Line | 5006 N HAMLIN AVE
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City | CHICAGO
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State | IL
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Zip | 60625-6018
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Country | US
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Telephone | 773-539-1983
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SUSAN WILCOSKI
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Credential | M.D.
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Telephone | 872-208-7709
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 036077561
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License Number State | IL
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