Provider Demographics
NPI:1558567636
Name:WELLCARE PHYSICIANS GROUP LLC
Entity Type:Organization
Organization Name:WELLCARE PHYSICIANS GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR, FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BURMEISTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-891-8024
Mailing Address - Street 1:4235 SECOR RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-4231
Mailing Address - Country:US
Mailing Address - Phone:419-214-4214
Mailing Address - Fax:419-479-5593
Practice Address - Street 1:5901 MONCLOVA RD
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1841
Practice Address - Country:US
Practice Address - Phone:419-891-8024
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH89211207Q00000X
OH207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2842704Medicaid
OH2842704Medicaid