Healthcare Provider Details

I. General information

NPI: 1588744940
Provider Name (Legal Business Name): WUNDERLICH MD SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 08/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 GLENWOOD AVE SUITE 107
JOLIET IL
60435-5676
US

IV. Provider business mailing address

2000 GLENWOOD AVE SUITE 107
JOLIET IL
60435-5676
US

V. Phone/Fax

Practice location:
  • Phone: 815-741-4445
  • Fax: 815-741-3047
Mailing address:
  • Phone: 815-741-4445
  • Fax: 815-741-3047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. ANDREW W WUNDERLICH
Title or Position: PRESIDENT
Credential: MD
Phone: 815-741-4445