Healthcare Provider Details

I. General information

NPI: 1760602254
Provider Name (Legal Business Name): WENONA HEALTH CENTER S C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 04/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 S. CHESTNUT ST
WENONA IL
61377
US

IV. Provider business mailing address

516 S. CHESTNUT ST PO BOX 250
WENONA IL
61377
US

V. Phone/Fax

Practice location:
  • Phone: 815-853-4402
  • Fax:
Mailing address:
  • Phone: 815-853-4402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. SAMUEL T BAZ
Title or Position: PRESIDENT
Credential: M.D.
Phone: 815-853-4402