Healthcare Provider Details

I. General information

NPI: 1891886164
Provider Name (Legal Business Name): STEPHANIE M WELLER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 12/10/2021
Certification Date: 12/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1945 W WILSON AVE STE 4000
CHICAGO IL
60640-5255
US

IV. Provider business mailing address

1945 W WILSON AVE STE 4000
CHICAGO IL
60640-5255
US

V. Phone/Fax

Practice location:
  • Phone: 773-736-6220
  • Fax: 773-736-3941
Mailing address:
  • Phone: 773-736-6220
  • Fax: 773-736-3941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036129096
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: