Provider Demographics
NPI:1982766390
Name:PEDIATRIC HEALTHCARE UNLIMITED
Entity type:Organization
Organization Name:PEDIATRIC HEALTHCARE UNLIMITED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:WUELLNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-474-1711
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL801561640000Medicaid
IL210823Medicare ID - Type Unspecified