Basic Information
| Provider Information | |||||||||
| NPI: | 1831488154 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SZE K WONG M D S C | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2323 S WENTWORTH AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606164615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3128420100 | ||||||||
| FaxNumber: | 3128424967 | ||||||||
| Practice Location | |||||||||
| Address1: | 2323 S WENTWORTH AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606164615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3128420100 | ||||||||
| FaxNumber: | 3128424967 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2011 | ||||||||
| LastUpdateDate: | 04/07/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WONG | ||||||||
| AuthorizedOfficialFirstName: | SZE | ||||||||
| AuthorizedOfficialMiddleName: | KIN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3128420100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 036078670 | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 036078670 | 05 | IL | MEDICAID |