Provider Demographics
NPI:1194706564
Name:WENDLAND, MARCIA LYNN (MD)
Entity type:Individual
Prefix:
First Name:MARCIA
Middle Name:LYNN
Last Name:WENDLAND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 BEAVER CREEK CT
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-5497
Mailing Address - Country:US
Mailing Address - Phone:618-233-0798
Mailing Address - Fax:618-233-0964
Practice Address - Street 1:5105 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-4728
Practice Address - Country:US
Practice Address - Phone:618-233-0798
Practice Address - Fax:618-233-5647
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036062393207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036062393Medicaid
IL671912Medicare PIN
C45405Medicare UPIN