MEDICARE: MR. ROBERT ANTHONY WISDOM CRNP

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	363LN0000X	Neonatal Nurse Practitioner	350263	NY
2	363LN0000X	Neonatal Nurse Practitioner	209014169	IL
3	363LN0000X	Neonatal Nurse Practitioner	942926-6	FL

General Provider Information

NPI Number	:	1487767117
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERT ANTHONY WISDOM CRNP

Provider Business Mailing Address
First Line	:	4444 S PRAIRIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60653-3208
Country	:	US
Telephone Number	:	917-362-6997
Fax Number	:

Provider Business Practice Location Address
First Line	:	4444 S PRAIRIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60653-3208
Country	:	US
Telephone Number	:	917-362-6997
Fax Number	:

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

Provider Enumeration Date	:	08/16/2006
Last Update Date	:	04/08/2016

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