MEDICARE: DR. MICHAEL FENTRISS WILSON M.D.

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	208600000X	Surgery Physician	036-060142	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083600027
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL FENTRISS WILSON M.D.

Provider Business Mailing Address
First Line	:	126 E WING ST
Second Line	:	#185
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60004-6064
Country	:	US
Telephone Number	:	847-560-4676
Fax Number	:	630-689-5809

Provider Business Practice Location Address
First Line	:	1555 BARRINGTON RD
Second Line	:	SUITE 2300B
City	:	HOFFMAN ESTATES
State	:	IL
Zip	:	60169-1019
Country	:	US
Telephone Number	:	847-843-0726
Fax Number	:

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

Provider Enumeration Date	:	09/26/2005
Last Update Date	:	08/14/2014

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