Healthcare Provider Details

I. General information

NPI: 1477856979
Provider Name (Legal Business Name): MARY O WUNDERLICH PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2010
Last Update Date: 01/25/2023
Certification Date: 01/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 SPRING STREET
RED BUD IL
62278
US

IV. Provider business mailing address

325 SPRING STREET
RED BUD IL
62278
US

V. Phone/Fax

Practice location:
  • Phone: 618-282-3831
  • Fax: 618-282-5476
Mailing address:
  • Phone: 618-282-3831
  • Fax: 618-282-5476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085-000332
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085000332
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: