Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207X00000X | Orthopaedic Surgeon | 036-116709 | IL |
N | 207XS0106X | Orthopaedic Hand Surgeon | 036116709 | IL |
NPI | 1275645319 |
---|---|
Provider Name | Robert Wysocki |
First Address | Westchester, IL 60154-5701 |
Second Address | Chicago, IL 60612-3841 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/08/2006 |
Last Update Date | 04/05/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036116709 | MEDICAL LICENSE (01) | IL |
036116709 2 | (05) | IL |
1633878 | BCBS ILLINOIS (01) | IL |
207067004 (207067) | (02) | IL |
207073004 ( 207073) | (02) | IL |
9429369 | AETNA (01) | |
P00836808 | RR MEDICARE (01) |