Healthcare Provider Details

I. General information

NPI: 1669623575
Provider Name (Legal Business Name): WELLCARE PHYSICIAN SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2008
Last Update Date: 10/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8905 S FRANCISCO AVE
EVERGREEN PARK IL
60805-1251
US

IV. Provider business mailing address

8905 S FRANCISCO AVE
EVERGREEN PARK IL
60805-1251
US

V. Phone/Fax

Practice location:
  • Phone: 708-359-7526
  • Fax:
Mailing address:
  • Phone: 708-359-7526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036099035
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number336059478
License Number StateIL

VIII. Authorized Official

Name: ENO NSIMA-OBOT
Title or Position: OWNER
Credential: M.D.
Phone: 708-359-7526