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General NPI Number Information
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NPI Number | 1154717916
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Entity Type | Individual
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Provider Name | FENG WEN
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Gender | Male
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Dates
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Enumeration Date | 04/08/2015
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Last Update Date | 08/10/2016
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Provider Practice Location Address
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Address Line | 6447 CERMAK RD
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City | BERWYN
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State | IL
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Zip | 60402-2311
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Country | US
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Telephone | 773-254-1400
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Fax | 708-656-0349
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Provider Business Mailing Address
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Address Line | 966 W 21ST ST
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City | CHICAGO
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State | IL
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Zip | 60608-4511
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Country | US
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Telephone | 773-254-1400
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Fax | 312-829-6842
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 085005886
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License Number State | IL
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