Healthcare Provider Details

I. General information

NPI: 1245541663
Provider Name (Legal Business Name): ANNA WAHLIG D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2010
Last Update Date: 06/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 LAKEVIEW DR
WATERLOO IL
62298-1847
US

IV. Provider business mailing address

703 LAKEVIEW DR
WATERLOO IL
62298-1847
US

V. Phone/Fax

Practice location:
  • Phone: 573-934-0363
  • Fax:
Mailing address:
  • Phone: 573-934-0363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2010020923
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: