Healthcare Provider Details

I. General information

NPI: 1639795669
Provider Name (Legal Business Name): COREY WHEELOCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2020
Last Update Date: 06/25/2021
Certification Date: 06/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 S CALIFORNIA AVE STE 1
CHICAGO IL
60608-1694
US

IV. Provider business mailing address

1 HOSPITAL DR # DC043.00
COLUMBIA MO
65212-1000
US

V. Phone/Fax

Practice location:
  • Phone: 773-565-3008
  • Fax: 773-522-5855
Mailing address:
  • Phone: 573-884-1606
  • Fax: 573-884-4533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2020017706
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number125078145
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: