Provider Demographics
NPI:1134238934
Name:WILCO FAMILY PRACTICE, LTD.
Entity type:Organization
Organization Name:WILCO FAMILY PRACTICE, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILCOSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:872-208-7709
Mailing Address - Street 1:5006 N HAMLIN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-6018
Mailing Address - Country:US
Mailing Address - Phone:773-539-1983
Mailing Address - Fax:
Practice Address - Street 1:2740 W FOSTER AVE
Practice Address - Street 2:SUITE 307
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3500
Practice Address - Country:US
Practice Address - Phone:872-208-7709
Practice Address - Fax:872-208-7703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036077561207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036077561Medicaid
E41113Medicare UPIN
IL036077561Medicaid