Provider Demographics
NPI:1487612834
Name:WILEY, JOHN ARTHUR (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ARTHUR
Last Name:WILEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 W DIVERSEY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-1513
Mailing Address - Country:US
Mailing Address - Phone:773-725-0990
Mailing Address - Fax:
Practice Address - Street 1:5300 W DIVERSEY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-1513
Practice Address - Country:US
Practice Address - Phone:773-725-0990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-069176207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036069176Medicaid
IL0031601867OtherBLUE SHIELD
IL0004531987OtherAETNA
IL752760Medicare PIN
ILD16045Medicare UPIN