Provider Demographics
NPI:1073037008
Name:WILSON, KEVIN M
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:M
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2547 W AUGUSTA BLVD # 4
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-4561
Mailing Address - Country:US
Mailing Address - Phone:773-573-7150
Mailing Address - Fax:708-575-0720
Practice Address - Street 1:2547 W AUGUSTA BLVD # 4
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-4561
Practice Address - Country:US
Practice Address - Phone:773-573-7150
Practice Address - Fax:708-575-0720
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies