Provider Demographics
NPI:1639287766
Name:WILSON, CARRIE C (MD)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:C
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 S BENNETT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60649-1501
Mailing Address - Country:US
Mailing Address - Phone:312-341-9373
Mailing Address - Fax:
Practice Address - Street 1:6801 S BENNETT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-1501
Practice Address - Country:US
Practice Address - Phone:312-341-9373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-055269207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD15533Medicare UPIN