Healthcare Provider Details

I. General information

NPI: 1902808611
Provider Name (Legal Business Name): WENDELL A WHEELER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 12/21/2021
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15821 S PARK AVE
SOUTH HOLLAND IL
60473-1506
US

IV. Provider business mailing address

15821 S PARK AVE
SOUTH HOLLAND IL
60473-1506
US

V. Phone/Fax

Practice location:
  • Phone: 708-225-0200
  • Fax: 708-225-0202
Mailing address:
  • Phone: 708-225-0200
  • Fax: 708-225-0202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-068196
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: