Basic Information
| Provider Information | |||||||||
| NPI: | 1013937176 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WELLS | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4801 W 81ST ST | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554371111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528379700 | ||||||||
| FaxNumber: | 9528379701 | ||||||||
| Practice Location | |||||||||
| Address1: | 4801 W 81ST ST | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554371111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528379700 | ||||||||
| FaxNumber: | 9528379701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 04/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 27565 | MN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 909295100 | 05 | MN | MEDICAID |