MEDICARE: DR. THEODORE SIDNEY WRIGHT JR. 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	207Q00000X	Family Medicine Physician	036065761	IL
2	2083X0100X	Occupational Medicine Physician	036065761	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	31601076	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1598830796
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THEODORE SIDNEY WRIGHT JR. M.D.

Provider Business Mailing Address
First Line	:	4757 W MONTROSE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-1504
Country	:	US
Telephone Number	:	773-777-2620
Fax Number	:	773-777-3030

Provider Business Practice Location Address
First Line	:	4757 W MONTROSE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-1504
Country	:	US
Telephone Number	:	773-777-2620
Fax Number	:	773-777-3030

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

Provider Enumeration Date	:	11/22/2006
Last Update Date	:	12/26/2012

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