Provider Demographics
NPI:1427020544
Name:WOLS, MATTHEW WARREN (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:WARREN
Last Name:WOLS
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 1:121 E 56TH ST
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-2033
Mailing Address - Country:US
Mailing Address - Phone:630-494-0192
Mailing Address - Fax:
Practice Address - Street 1:925 WEST ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-2757
Practice Address - Country:US
Practice Address - Phone:815-223-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036093915207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036093915Medicaid
ILG58740Medicare UPIN