Provider Demographics
NPI:1285164277
Name:WILSON, ROBERT KENT (DO)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:KENT
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 WAUKEGAN RD STE 200
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-2724
Mailing Address - Country:US
Mailing Address - Phone:847-242-6600
Mailing Address - Fax:847-242-6605
Practice Address - Street 1:27100 CHARDON RD
Practice Address - Street 2:UNIVERSITY HOSPITALS RICHMOND MEDICAL CENTER
Practice Address - City:RICHMOND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44143
Practice Address - Country:US
Practice Address - Phone:216-844-8447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-13
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036154030207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program