Healthcare Provider Details

I. General information

NPI: 1649237504
Provider Name (Legal Business Name): WENDELL W BECTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 01/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 TRINITY LANE SUITE 111
BLOOMINGTON IL
61704-3738
US

IV. Provider business mailing address

1111 TRINITY LANE SUITE 111
BLOOMINGTON IL
61704-3738
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-6461
  • Fax: 309-663-5711
Mailing address:
  • Phone: 309-663-6461
  • Fax: 309-663-5711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number036093050
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: