Provider Demographics
NPI:1902915796
Name:WILCOSKI, SUSAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:WILCOSKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5006 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
Is Sole Proprietor?:Yes
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?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036077561Medicaid
IL036077561Medicaid
E41113Medicare UPIN