Provider Demographics
NPI:1427095629
Name:WHITE, G WESLEY (MD)
Entity type:Individual
Prefix:
First Name:G
Middle Name:WESLEY
Last Name:WHITE
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 1:25 N WINFIELD RD
Mailing Address - Street 2:OPS BUILDING, SUITE 507
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1295
Mailing Address - Country:US
Mailing Address - Phone:630-933-5518
Mailing Address - Fax:630-933-4168
Practice Address - Street 1:25 N WINFIELD RD
Practice Address - Street 2:OPS BUILDING, SUITE 507
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1295
Practice Address - Country:US
Practice Address - Phone:630-933-5518
Practice Address - Fax:630-933-4168
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2013-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036051494207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036051494Medicaid
ILK49356OtherMEDICARE PTAN (INDIVIDUAL)
ILP00661626OtherRR MEDICARE PTAN (INDIVIDUAL)
IL01635822OtherBCBS PROVIDER ID
ILP00448441OtherRAILROAD MEDICARE
IL206147OtherMEDICARE PTAN (GROUP
IL036051494Medicaid