Provider Demographics
NPI:1104929405
Name:WELLMAN, ROBERT (BRUCE) B (MD)
Entity type:Individual
Prefix:
First Name:ROBERT (BRUCE)
Middle Name:B
Last Name:WELLMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W. PARK ST
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6941
Mailing Address - Fax:217-383-4752
Practice Address - Street 1:611 W. PARK ST
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2500
Practice Address - Country:US
Practice Address - Phone:217-383-3342
Practice Address - Fax:217-383-4260
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036062748207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC43472Medicare UPIN
IL6447860011Medicare NSC
C43472Medicare UPIN
ILIL3270044Medicare PIN