Basic Information
| Provider Information | |||||||||
| NPI: | 1679744833 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WANG | ||||||||
| FirstName: | RALPH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2180 WEST MANCHESTER RD | ||||||||
| Address2: | |||||||||
| City: | WHEATON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7085674538 | ||||||||
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| Practice Location | |||||||||
| Address1: | 235 WEALTHY ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495035247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6168408005 | ||||||||
| FaxNumber: | 6168409642 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2008 | ||||||||
| LastUpdateDate: | 03/31/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 4301117210 | MI | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | BP10023392 | TX | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | 036120935 | IL | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 036120935-1 | 05 | IL | MEDICAID |