Healthcare Provider Details

I. General information

NPI: 1881378032
Provider Name (Legal Business Name): CHLOE EMMA WAHL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2023
Last Update Date: 06/17/2023
Certification Date: 06/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 N RUTLEDGE ST RM 1100
SPRINGFIELD IL
62702-4968
US

IV. Provider business mailing address

PO BOX 19636
SPRINGFIELD IL
62794-9636
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax: 217-545-4735
Mailing address:
  • Phone: 217-545-8000
  • Fax: 217-545-4735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number125082506
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125082506
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: