Provider Demographics
NPI:1407810823
Name:WIELGOS, ANNE M (PT)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:M
Last Name:WIELGOS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ANNE
Other - Middle Name:M
Other - Last Name:MCINTYRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:926 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-7829
Practice Address - Country:US
Practice Address - Phone:630-858-8484
Practice Address - Fax:630-858-9006
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012248225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL2993011Medicare PIN
ILP00438883Medicare PIN
IL214708006Medicare PIN
ILK38360Medicare PIN