Provider Demographics
NPI:1871789545
Name:BURGESS CHRISTIANSEN WILSON, MD, CHARTERED
Entity type:Organization
Organization Name:BURGESS CHRISTIANSEN WILSON, MD, CHARTERED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BURGESS
Authorized Official - Middle Name:C
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-223-9202
Mailing Address - Street 1:25 E WASHINGTON ST
Mailing Address - Street 2:SUITE 1714
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-1708
Mailing Address - Country:US
Mailing Address - Phone:312-223-9202
Mailing Address - Fax:312-223-9203
Practice Address - Street 1:25 E WASHINGTON ST
Practice Address - Street 2:SUITE 1714
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-1708
Practice Address - Country:US
Practice Address - Phone:312-223-9202
Practice Address - Fax:312-223-9203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-17
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209998Medicare PIN