Healthcare Provider Details

I. General information

NPI: 1295022945
Provider Name (Legal Business Name): STEPHAN V WALCHUK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2011
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1304 FRANKLIN AVE
NORMAL IL
61761-3558
US

IV. Provider business mailing address

611 W PARK ST
URBANA IL
61801-2501
US

V. Phone/Fax

Practice location:
  • Phone: 309-268-5130
  • Fax: 309-268-5784
Mailing address:
  • Phone: 217-383-3311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036.134906
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: