Provider Demographics
NPI:1588789465
Name:WHEATON FAMILY PRACTICE, LTD.
Entity type:Organization
Organization Name:WHEATON FAMILY PRACTICE, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:CORRINE
Authorized Official - Last Name:GLAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-665-6500
Mailing Address - Street 1:393 S SCHMALE RD
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60188-2765
Mailing Address - Country:US
Mailing Address - Phone:630-665-6500
Mailing Address - Fax:630-665-1411
Practice Address - Street 1:393 S SCHMALE RD
Practice Address - Street 2:
Practice Address - City:CAROL STREAM
Practice Address - State:IL
Practice Address - Zip Code:60188-2765
Practice Address - Country:US
Practice Address - Phone:630-665-6500
Practice Address - Fax:630-665-1411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL203879Medicare ID - Type Unspecified