Provider Demographics
NPI:1699739896
Name:WELLGROUP HEALTHPARTNERS LLC
Entity type:Organization
Organization Name:WELLGROUP HEALTHPARTNERS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCORMICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-756-0100
Mailing Address - Street 1:333 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-1748
Mailing Address - Country:US
Mailing Address - Phone:708-754-4890
Mailing Address - Fax:708-709-6242
Practice Address - Street 1:333 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-1748
Practice Address - Country:US
Practice Address - Phone:708-754-4890
Practice Address - Fax:708-709-6242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL7002769261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7002769OtherLICENSE ID NUMBER
IL7002769OtherLICENSE ID NUMBER