Provider Demographics
NPI:1528126893
Name:WELLER, HERSCHEL MYRON (MD)
Entity type:Individual
Prefix:
First Name:HERSCHEL
Middle Name:MYRON
Last Name:WELLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2050 PFINGSTEN RD
Mailing Address - Street 2:STE. 330
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-1324
Mailing Address - Country:US
Mailing Address - Phone:847-998-4100
Mailing Address - Fax:847-998-6769
Practice Address - Street 1:2050 PFINGSTEN RD
Practice Address - Street 2:STE. 330
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-1324
Practice Address - Country:US
Practice Address - Phone:847-998-4100
Practice Address - Fax:847-998-6769
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036-047535207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD13090Medicare UPIN