MEDICARE: MR. KEVIN M WILSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1073037008
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KEVIN M WILSON

Provider Business Mailing Address
First Line	:	2547 W AUGUSTA BLVD # 4
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-4561
Country	:	US
Telephone Number	:	773-573-7150
Fax Number	:	708-575-0720

Provider Business Practice Location Address
First Line	:	2547 W AUGUSTA BLVD # 4
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-4561
Country	:	US
Telephone Number	:	773-573-7150
Fax Number	:	708-575-0720

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2017
Last Update Date	:	07/21/2022

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