Healthcare Provider Details

I. General information

NPI: 1528024254
Provider Name (Legal Business Name): BRETT A. WURTH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 10/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MEMORIAL MEDICAL CTR 701 N 1ST STREET
SPRINGFIELD IL
62781-0001
US

IV. Provider business mailing address

701 N 1ST ST
SPRINGFIELD IL
62781-0001
US

V. Phone/Fax

Practice location:
  • Phone: 217-788-5495
  • Fax: 217-788-5496
Mailing address:
  • Phone: 217-788-5495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036114802
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: