MEDICARE: DR. LOYD J WOLLSTADT M.D.

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	207R00000X	Internal Medicine Physician	036050197	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	036050197	OTHER	IL	IL STATE LICENSE

General Provider Information

NPI Number	:	1356332498
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LOYD J WOLLSTADT M.D.

Provider Business Mailing Address
First Line	:	1601 PARKVIEW AVE
Second Line	:	CREDENTIALING S200
City	:	ROCKFORD
State	:	IL
Zip	:	61107-1822
Country	:	US
Telephone Number	:	815-395-5861
Fax Number	:	815-395-5575

Provider Business Practice Location Address
First Line	:	405 CHARLES ST
Second Line	:	UNIVERSITY PRIMARY CARE CLINIC MT MORRIS
City	:	MOUNT MORRIS
State	:	IL
Zip	:	61054-1646
Country	:	US
Telephone Number	:	815-734-6061
Fax Number	:	815-734-9021

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/28/2005
Last Update Date	:	09/03/2010

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