Provider Demographics
NPI:1326020264
Name:WELLINGHOFF, JEROME W (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JEROME
Middle Name:W
Last Name:WELLINGHOFF
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4010 RIVERKNOLL DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-9213
Mailing Address - Country:US
Mailing Address - Phone:217-356-5963
Mailing Address - Fax:217-352-8947
Practice Address - Street 1:4010 RIVERKNOLL DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-9213
Practice Address - Country:US
Practice Address - Phone:217-356-5963
Practice Address - Fax:217-352-8947
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL09223524OtherBC/BS GROUP ID NO.
ILCG3273OtherRR MEDICARE GROUP ID NO.
IL371390028001OtherTRICARE GROUP ID NO.
IL371390028001OtherTRICARE GROUP ID NO.
IL09223524OtherBC/BS GROUP ID NO.