Provider Demographics
NPI:1124319215
Name:ILLING, ANTHONY CHRISTOPHER (MD)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:CHRISTOPHER
Last Name:ILLING
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 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-2060
Mailing Address - Fax:414-259-9290
Practice Address - Street 1:1905 N CALHOUN RD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5005
Practice Address - Country:US
Practice Address - Phone:262-754-8000
Practice Address - Fax:262-780-3396
Is Sole Proprietor?:No
Enumeration Date:2011-04-25
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01076842A2085R0202X
WI814842085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1124319215Medicaid