Provider Demographics
NPI:1477563773
Name:WOOLEY, R. SCOTT
Entity Type:Individual
Prefix:
First Name:R.
Middle Name:SCOTT
Last Name:WOOLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 GREENLAW BLVD
Mailing Address - Street 2:
Mailing Address - City:FLORA
Mailing Address - State:IL
Mailing Address - Zip Code:62839-1300
Mailing Address - Country:US
Mailing Address - Phone:618-662-8468
Mailing Address - Fax:618-662-4371
Practice Address - Street 1:23 GREENLAW BLVD
Practice Address - Street 2:
Practice Address - City:FLORA
Practice Address - State:IL
Practice Address - Zip Code:62839-1300
Practice Address - Country:US
Practice Address - Phone:618-662-8468
Practice Address - Fax:618-662-4371
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008137152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0259160001Medicare NSC
ILT39126Medicare UPIN
IL441950Medicare PIN