Provider Demographics
NPI:1407835366
Name:WALLNER, HARRY R (MD)
Entity Type:Individual
Prefix:DR
First Name:HARRY
Middle Name:R
Last Name:WALLNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1236 E RUSHOLME ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-2473
Mailing Address - Country:US
Mailing Address - Phone:563-324-2992
Mailing Address - Fax:563-888-0499
Practice Address - Street 1:1100 36TH AVENUE
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265
Practice Address - Country:US
Practice Address - Phone:309-743-6700
Practice Address - Fax:309-764-2042
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036058715207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0556977Medicaid
IL036058715Medicaid
060053307OtherMEDICARE RAILROAD
C38001Medicare UPIN
ILL72066Medicare PIN
IA0556977Medicaid