Provider Demographics
NPI:1912190901
Name:CARL M. WAHLSTROM, JR., M.D., LIMITED
Entity Type:Organization
Organization Name:CARL M. WAHLSTROM, JR., M.D., LIMITED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:M
Authorized Official - Last Name:WAHLSTROM
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:312-782-7895
Mailing Address - Street 1:307 N MICHIGAN AVE
Mailing Address - Street 2:SUITE 1008
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-5311
Mailing Address - Country:US
Mailing Address - Phone:312-782-7895
Mailing Address - Fax:312-782-7897
Practice Address - Street 1:307 N MICHIGAN AVE
Practice Address - Street 2:SUITE 1008
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-5311
Practice Address - Country:US
Practice Address - Phone:312-782-7895
Practice Address - Fax:312-782-7897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208858Medicare PIN