Provider Demographics
NPI:1083600027
Name:WILSON, MICHAEL FENTRISS (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:FENTRISS
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 E WING ST
Mailing Address - Street 2:#185
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-6064
Mailing Address - Country:US
Mailing Address - Phone:847-560-4676
Mailing Address - Fax:630-689-5809
Practice Address - Street 1:1555 BARRINGTON RD
Practice Address - Street 2:SUITE 2300B
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60169-1019
Practice Address - Country:US
Practice Address - Phone:847-843-0726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-26
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-060142208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-060142Medicaid
IL036-060142Medicaid