Provider Demographics
NPI:1245418847
Name:ANDREW WAHL AND ADA PAOLUCCI
Entity Type:Organization
Organization Name:ANDREW WAHL AND ADA PAOLUCCI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ADA
Authorized Official - Middle Name:VERA
Authorized Official - Last Name:PAOLUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:815-436-3555
Mailing Address - Street 1:1960 ESSINGTON RD
Mailing Address - Street 2:STE 103
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-1617
Mailing Address - Country:US
Mailing Address - Phone:815-436-3555
Mailing Address - Fax:815-436-3578
Practice Address - Street 1:1960 ESSINGTON RD
Practice Address - Street 2:STE 103
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-1617
Practice Address - Country:US
Practice Address - Phone:815-436-3555
Practice Address - Fax:815-436-3578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0016004462213E00000X
IL213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5536200001Medicare NSC