Provider Demographics
NPI:1548216195
Name:WYNN, RAYMOND B (MD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:B
Last Name:WYNN
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 1:125 OAK RIDGE DR E
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-6869
Mailing Address - Country:US
Mailing Address - Phone:087-635-9133
Mailing Address - Fax:
Practice Address - Street 1:2500 WEST 12TH STREET
Practice Address - Street 2:UPMC REGIONAL CANCER CENTER
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505
Practice Address - Country:US
Practice Address - Phone:708-635-9133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4386112085R0001X
IL0361426022085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051542649OtherBCBS - ONE INFIRMARY CIRCLE
FL276857700Medicaid
AL009934193Medicaid
PA1023982380001Medicaid
AL3600240OtherUNITED HEALTH CARE
MS00118037Medicaid
AL51531394OtherBLUE CROSS
AL51593896OtherBCBS - 1660 SPRINGHILL
PA2117379OtherHIGHMARK
AL51593896OtherBCBS - 1660 SPRINGHILL
PA167307Medicare PIN
AL051559789Medicare PIN