Provider Demographics
NPI:1275557498
Name:CARLSON, WADE (MD)
Entity Type:Individual
Prefix:DR
First Name:WADE
Middle Name:
Last Name:CARLSON
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 1:5114 N GLEN PARK PLACE RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4686
Mailing Address - Country:US
Mailing Address - Phone:309-683-6600
Mailing Address - Fax:309-683-2412
Practice Address - Street 1:5114 N GLEN PARK PLACE RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4686
Practice Address - Country:US
Practice Address - Phone:309-683-6600
Practice Address - Fax:309-683-2412
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036101444207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL01R8OtherJOHN DEERE
IL0361014441Medicaid
IL472307OtherHEALTHLINK
ILP00187651OtherRAILROAD MEDICARE
IL095222OtherHEALTH ALLIANCE
IL7215059OtherBCBS PPO
IL7215059OtherBCBS PPO
ILI12816Medicare UPIN