Provider Demographics
NPI:1831488154
Name:SZE K WONG M D S C
Entity Type:Organization
Organization Name:SZE K WONG M D S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SZE
Authorized Official - Middle Name:KIN
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-842-0100
Mailing Address - Street 1:2323 S WENTWORTH AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-4615
Mailing Address - Country:US
Mailing Address - Phone:312-842-0100
Mailing Address - Fax:312-842-4967
Practice Address - Street 1:2323 S WENTWORTH AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-4615
Practice Address - Country:US
Practice Address - Phone:312-842-0100
Practice Address - Fax:312-842-4967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036078670261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036078670Medicaid
ILE19052Medicare UPIN