Healthcare Provider Details

I. General information

NPI: 1790215747
Provider Name (Legal Business Name): ANNA THERESA WILEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2017
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 MERCY DR
COUNCIL BLUFFS IA
51503-3128
US

IV. Provider business mailing address

800 MERCY DR
COUNCIL BLUFFS IA
51503-3128
US

V. Phone/Fax

Practice location:
  • Phone: 855-524-4001
  • Fax: 712-325-2499
Mailing address:
  • Phone: 855-524-4001
  • Fax: 712-325-2499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number32578
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125.071133
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number32578
License Number StateNE
# 4
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD-53952
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: