MEDICARE: WELLCARE PHYSICIANS GROUP LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician		OH

General Provider Information

NPI Number	:	1265875959
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLCARE PHYSICIANS GROUP LLC

Provider Business Mailing Address
First Line	:	6135 TRUST DR
Second Line	:	SUITE 114
City	:	HOLLAND
State	:	OH
Zip	:	43528-9358
Country	:	US
Telephone Number	:	419-491-0041
Fax Number	:	419-491-0042

Provider Business Practice Location Address
First Line	:	6135 TRUST DR
Second Line	:	SUITE 114
City	:	HOLLAND
State	:	OH
Zip	:	43528-9358
Country	:	US
Telephone Number	:	419-491-0041
Fax Number	:	419-491-0042

Authorized Official
Title or Position	:	CREDENTIALING SUPERVISOR
Name	:	AMY L BAHNSEN
Credential	:
Telephone Number	:	419-824-7334

Provider Enumeration Date	:	04/11/2013
Last Update Date	:	04/11/2013

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