Healthcare Provider Details

I. General information

NPI: 1962537332
Provider Name (Legal Business Name): KATHIE R. WUELLNER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHIE R ROSENTRETER

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 07/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 MEMORIAL DR. STE 110
ALTON IL
62002
US

IV. Provider business mailing address

4 MEMORIAL DR. STE 110
ALTON IL
62002
US

V. Phone/Fax

Practice location:
  • Phone: 618-474-1711
  • Fax: 618-474-2793
Mailing address:
  • Phone: 618-474-1711
  • Fax: 618-474-2793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-059452
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: