=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669356119
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSEPH WANG DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2025
-----------------------------------------------------
Last Update Date | 08/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4705 W FOSTER AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60630-1710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-273-6534
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6608 N ARTESIAN AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60645-5017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-318-5470
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 070.028673
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------