Provider Demographics
NPI:1467877118
Name:WILDE, MAXIMINO
Entity Type:Individual
Prefix:
First Name:MAXIMINO
Middle Name:
Last Name:WILDE
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 1:8059 E PRAIRIE RD
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-3446
Mailing Address - Country:US
Mailing Address - Phone:773-678-6718
Mailing Address - Fax:
Practice Address - Street 1:3703 W LAKE AVE
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-5823
Practice Address - Country:US
Practice Address - Phone:847-904-5022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-04
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1600006607225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant