Provider Demographics
NPI:1184629701
Name:WELLMAN, RICHARD W (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:W
Last Name:WELLMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 EASTLAND DR STE 100
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-7906
Mailing Address - Country:US
Mailing Address - Phone:309-663-8888
Mailing Address - Fax:309-277-2359
Practice Address - Street 1:1505 EASTLAND DR STE 100
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-7906
Practice Address - Country:US
Practice Address - Phone:309-663-8888
Practice Address - Fax:309-277-2359
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036091292207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036091292Medicaid
IL036091292Medicaid
IL685440Medicare ID - Type Unspecified
A92840Medicare UPIN
ILL40918Medicare PIN