Basic Information
| Provider Information | |||||||||
| NPI: | 1154548089 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WU | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 W CENTRAL RD | ||||||||
| Address2: | DEPARTMENT OF EMERGENCY MEDICINE | ||||||||
| City: | ARLINGTON HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600052349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476183040 | ||||||||
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| Practice Location | |||||||||
| Address1: | 800 W CENTRAL RD | ||||||||
| Address2: | DEPARTMENT OF EMERGENCY MEDICINE | ||||||||
| City: | ARLINGTON HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600052349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476183040 | ||||||||
| FaxNumber: | 8476183049 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2007 | ||||||||
| LastUpdateDate: | 07/14/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 036-114930 | IL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036114930 | 01 | IL | BLUE CROSS BLUE SHIELD OF ILLINOIS | OTHER | 1154548089 | 05 | IL | MEDICAID |