Healthcare Provider Details

I. General information

NPI: 1720012024
Provider Name (Legal Business Name): VIRGINIA A WADE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 05/31/2024
Certification Date: 05/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 E COUNTY ROAD 300 N
ARCOLA IL
61910
US

IV. Provider business mailing address

600 E COUNTY ROAD 300 N
ARCOLA IL
61910
US

V. Phone/Fax

Practice location:
  • Phone: 217-268-5008
  • Fax: 217-268-5010
Mailing address:
  • Phone: 217-268-5008
  • Fax: 217-268-5010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.061619
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: