Provider Demographics
NPI:1386738060
Name:WONG, SHIRLEY S (MD)
Entity type:Individual
Prefix:DR
First Name:SHIRLEY
Middle Name:S
Last Name:WONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 S MICHIGAN AVE STE 408
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-2696
Mailing Address - Country:US
Mailing Address - Phone:312-808-9000
Mailing Address - Fax:
Practice Address - Street 1:2600 S MICHIGAN AVE STE 408
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-2696
Practice Address - Country:US
Practice Address - Phone:312-808-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2021-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036070413207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360704132Medicaid
ILC39243Medicare UPIN
ILL60358Medicare ID - Type Unspecified