Provider Demographics
NPI:1962537332
Name:WUELLNER, KATHIE R (MD)
Entity type:Individual
Prefix:DR
First Name:KATHIE
Middle Name:R
Last Name:WUELLNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHIE
Other - Middle Name:R
Other - Last Name:ROSENTRETER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4 MEMORIAL DR.
Mailing Address - Street 2:STE 110
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002
Mailing Address - Country:US
Mailing Address - Phone:618-474-1711
Mailing Address - Fax:618-474-2793
Practice Address - Street 1:4 MEMORIAL DR.
Practice Address - Street 2:STE 110
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002
Practice Address - Country:US
Practice Address - Phone:618-474-1711
Practice Address - Fax:618-474-2793
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-059452208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036059452Medicaid
ILK14204Medicare ID - Type Unspecified