Provider Demographics
NPI:1407044241
Name:WU, SIMON K (MD)
Entity Type:Individual
Prefix:
First Name:SIMON
Middle Name:K
Last Name:WU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KWOK
Other - Middle Name:WAI
Other - Last Name:WU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:400 N WALL ST STE 303
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-2964
Mailing Address - Country:US
Mailing Address - Phone:815-933-1664
Mailing Address - Fax:815-935-5660
Practice Address - Street 1:400 N WALL ST STE 303
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-2964
Practice Address - Country:US
Practice Address - Phone:815-933-1664
Practice Address - Fax:815-935-5660
Is Sole Proprietor?:No
Enumeration Date:2007-10-05
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036089802207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
04623007OtherBCBS OF ILLINOIS
IL036089802Medicaid
F45862Medicare UPIN
547950Medicare PIN