Provider Demographics
NPI:1518146380
Name:PATRICK L WYFFELS, MD, LTD
Entity Type:Organization
Organization Name:PATRICK L WYFFELS, MD, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WYFFELS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-589-0600
Mailing Address - Street 1:5401 N KNOXVILLE AVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5098
Mailing Address - Country:US
Mailing Address - Phone:309-589-0600
Mailing Address - Fax:309-589-0602
Practice Address - Street 1:5401 N KNOXVILLE AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5098
Practice Address - Country:US
Practice Address - Phone:309-589-0600
Practice Address - Fax:309-589-0602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212916Medicare PIN