Healthcare Provider Details

I. General information

NPI: 1790862977
Provider Name (Legal Business Name): ROBERT LEO WELLNER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 01/02/2024
Certification Date: 01/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1461 COLESVILLE RD
BETHLEHEM PA
18015-5221
US

IV. Provider business mailing address

1461 COLESVILLE RD
BETHLEHEM PA
18015-5221
US

V. Phone/Fax

Practice location:
  • Phone: 610-442-7807
  • Fax: 609-895-1032
Mailing address:
  • Phone: 610-442-7807
  • Fax: 609-895-1032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberOS011916
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number25MB07771400
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberOS011916
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number20A8689
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: