Provider Demographics
NPI:1588744940
Name:WUNDERLICH MD SC
Entity type:Organization
Organization Name:WUNDERLICH MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:W
Authorized Official - Last Name:WUNDERLICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-741-4445
Mailing Address - Street 1:2000 GLENWOOD AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-5676
Mailing Address - Country:US
Mailing Address - Phone:815-741-4445
Mailing Address - Fax:815-741-3047
Practice Address - Street 1:2000 GLENWOOD AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-5676
Practice Address - Country:US
Practice Address - Phone:815-741-4445
Practice Address - Fax:815-741-3047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210137Medicare PIN