Provider Demographics
NPI:1508867144
Name:WILSON, RICHARD A (DO)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:A
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12251 S 80TH AVE
Mailing Address - Street 2:SUITE 1630
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1256
Mailing Address - Country:US
Mailing Address - Phone:708-923-5173
Mailing Address - Fax:708-923-5018
Practice Address - Street 1:15300 WEST AVE
Practice Address - Street 2:SUITE 20
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-4600
Practice Address - Country:US
Practice Address - Phone:708-460-5550
Practice Address - Fax:708-226-2595
Is Sole Proprietor?:No
Enumeration Date:2005-08-04
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036065125207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036065125Medicaid
ILF400265424OtherMEDICARE PTAN
ILD88631Medicare UPIN
010034917Medicare PIN
P10827Medicare PIN