Provider Demographics
NPI:1508861840
Name:CHILCOTE, WAYNE S JR (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:S
Last Name:CHILCOTE
Suffix:JR
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 1:123 PRIMROSE LN
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MT
Mailing Address - Zip Code:59840-9508
Mailing Address - Country:US
Mailing Address - Phone:406-531-1081
Mailing Address - Fax:
Practice Address - Street 1:123 PRIMROSE LN
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MT
Practice Address - Zip Code:59840-9508
Practice Address - Country:US
Practice Address - Phone:406-531-1081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI324272085R0202X
MT69532085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31885700Medicaid
WI31885700Medicaid
WI0082Medicare ID - Type Unspecified