Basic Information
| Provider Information | |||||||||
| NPI: | 1699930701 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLGROUP HEALTHPARTNERS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 DIXIE HWY | ||||||||
| Address2: | |||||||||
| City: | CHICAGO HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604111748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087560100 | ||||||||
| FaxNumber: | 7087096353 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 DIXIE HWY | ||||||||
| Address2: | |||||||||
| City: | CHICAGO HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604111748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087560100 | ||||||||
| FaxNumber: | 7087096353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2008 | ||||||||
| LastUpdateDate: | 07/29/2008 | ||||||||
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| AuthorizedOfficialLastName: | SORRENTINO | ||||||||
| AuthorizedOfficialFirstName: | PAT | ||||||||
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| AuthorizedOfficialTitleorPosition: | SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 7087096396 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | 042001344 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology | 207N00000X | 042001344 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207Q00000X | 042001344 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | 042001344 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207U00000X | 042001344 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Nuclear Medicine | 207V00000X | 042001344 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207W00000X | 042001344 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology | 207X00000X | 042001344 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207Y00000X | 042001344 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | 208000000X | 042001344 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2084N0400X | 042001344 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2085R0202X | 042001344 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085U0001X | 042001344 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 208600000X | 042001344 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208800000X | 042001344 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 01633874 | 01 | IL | BLUE CROSS BLUE SHIELF OF ILL DME PROVIDER NUMBER | OTHER |