Healthcare Provider Details

I. General information

NPI: 1558378927
Provider Name (Legal Business Name): DR. JOHN C WUELLNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 03/29/2024
Certification Date: 03/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 MEMORIAL DR SUITE 220
ALTON IL
62002-6723
US

IV. Provider business mailing address

670 MASON RIDGE CENTER DR STE. 300
SAINT LOUIS MO
63141-8573
US

V. Phone/Fax

Practice location:
  • Phone: 618-474-1723
  • Fax: 618-462-6989
Mailing address:
  • Phone: 618-474-1723
  • Fax: 618-462-5450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036061448
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: