Provider Demographics
NPI:1972590362
Name:WU, KAN Y (MD)
Entity Type:Individual
Prefix:
First Name:KAN
Middle Name:Y
Last Name:WU
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:PO BOX 770
Mailing Address - Street 2:907 WEST LINCOLN AVE
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-2413
Mailing Address - Country:US
Mailing Address - Phone:217-345-2500
Mailing Address - Fax:217-345-8366
Practice Address - Street 1:907 WEST LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-2413
Practice Address - Country:US
Practice Address - Phone:217-345-2500
Practice Address - Fax:217-345-8366
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361137122085R0202X
NE18855174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036113712Medicaid
NE01098OtherBCBS OF NE
NEE69988Medicare UPIN
ILK27823Medicare PIN
NE277304Medicare ID - Type Unspecified