Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 036-064142 | IL |
N | 207QG0300X | Family Doctor - Geriatric Medicine | 036-064142 | IL |
NPI | 1326144015 |
---|---|
Provider Name | Philip Ka-Hing Wong |
First Address | Morton Grove, IL 60053-3232 |
Second Address | Chicago, IL 60615-2400 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/09/2006 |
Last Update Date | 04/05/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036-064142 | STATE LICENSE (01) | IL |
E12705 | (02) | IL |