Healthcare Provider Details

I. General information

NPI: 1114149770
Provider Name (Legal Business Name): BRIAN J WHEATLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 05/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 W. PARK ST. HVI
URBANA IL
61801-2500
US

IV. Provider business mailing address

611 W. PARK ST. BWPC
URBANA IL
61803-6002
US

V. Phone/Fax

Practice location:
  • Phone: 217-904-7000
  • Fax: 217-904-7742
Mailing address:
  • Phone: 217-383-6792
  • Fax: 217-383-4752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301083680
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: