Provider Demographics
NPI:1336145036
Name:WOLIN, PRESTON MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:PRESTON
Middle Name:MICHAEL
Last Name:WOLIN
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 1:830 W DIVERSEY PKWY
Mailing Address - Street 2:STE 300
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1454
Mailing Address - Country:US
Mailing Address - Phone:773-248-4150
Mailing Address - Fax:773-248-4291
Practice Address - Street 1:830 W DIVERSEY PKWY
Practice Address - Street 2:STE 300
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1454
Practice Address - Country:US
Practice Address - Phone:773-248-4150
Practice Address - Fax:773-248-4291
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-060229207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
B99041Medicare UPIN
935230Medicare ID - Type Unspecified