Healthcare Provider Details

I. General information

NPI: 1720303605
Provider Name (Legal Business Name): ARCHANA WAGLE M D A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2010
Last Update Date: 07/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 JOHN DEERE RD
MOLINE IL
61265-6892
US

IV. Provider business mailing address

925 SHERWOOD DR
LAKE BLUFF IL
60044-2203
US

V. Phone/Fax

Practice location:
  • Phone: 309-779-5000
  • Fax:
Mailing address:
  • Phone: 847-615-2200
  • Fax: 847-615-2858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036100676
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number036100676
License Number StateIL

VIII. Authorized Official

Name: ARCHANA WAGLE
Title or Position: OWNER
Credential: MD
Phone: 847-615-2200