MEDICARE: DR. PAUL WANG MD

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	207Q00000X	Family Medicine Physician	036092209	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
6	80096082	OTHER		RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4255D7	OTHER	ID	JOHN DEERE NUMBER
2	91488	OTHER	IL	BLUE CROSS WELLMARK
3	60636	OTHER	IL	HEALTH ALLIANCE
4	143603	OTHER	IL	IHS
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	2263301	OTHER	IL	PHCS

General Provider Information

NPI Number	:	1508839481
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PAUL WANG MD

Provider Business Mailing Address
First Line	:	104 W 18TH AVE
Second Line	:
City	:	COAL VALLEY
State	:	IL
Zip	:	61240-9337
Country	:	US
Telephone Number	:	309-799-7518
Fax Number	:	309-799-3886

Provider Business Practice Location Address
First Line	:	104 W 18TH AVE
Second Line	:
City	:	COAL VALLEY
State	:	IL
Zip	:	61240-9337
Country	:	US
Telephone Number	:	309-799-7518
Fax Number	:	309-799-3886

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

Provider Enumeration Date	:	02/10/2006
Last Update Date	:	01/15/2014

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Directions to “ DR. PAUL WANG MD” Practice Location

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