MEDICARE: DR. DAVID T. WELLS PH.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	14842	OTHER	MO	BCBS MO
2	6072011	OTHER	IL	BCBS IL
3	6111855	OTHER	IL	UNITED HEALTHCARE
4	126302	OTHER	IL	HEALTHLINK
5	R18036	OTHER	IL	MERCY HEALTH PLANS
6	048560	OTHER	IL	VALUE OPTIONS
7	1733254	OTHER	IL	FIRST HEALTH
8	5823117	OTHER	IL	AETNA

General Provider Information

NPI Number	:	1881628782
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID T. WELLS PH.D

Provider Business Mailing Address
First Line	:	6-B GLEN-ED PROFESSIONAL PARK
Second Line	:
City	:	GLEN CARBON
State	:	IL
Zip	:	62034-3333
Country	:	US
Telephone Number	:	618-692-9600
Fax Number	:	618-692-9607

Provider Business Practice Location Address
First Line	:	6-B GLEN-ED PROFESSIONAL PARK
Second Line	:
City	:	GLEN CARBON
State	:	IL
Zip	:	62034-3333
Country	:	US
Telephone Number	:	618-692-9600
Fax Number	:	618-692-9607

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	07/08/2007

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