Provider Demographics
NPI:1932185584
Name:WILSON, MICHAEL RICHARD (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:RICHARD
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 E ERIE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3167
Mailing Address - Country:US
Mailing Address - Phone:312-238-1000
Mailing Address - Fax:
Practice Address - Street 1:900 SKOKIE BLVD
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-4012
Practice Address - Country:US
Practice Address - Phone:847-272-7426
Practice Address - Fax:847-412-6440
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO25780208100000X
IL036.110638208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR269763Medicaid
OR269763Medicaid
131879Medicare ID - Type Unspecified