Provider Demographics
NPI:1710455738
Name:PHYSICIANS WELLNESS ASSOCIATES LLC
Entity Type:Organization
Organization Name:PHYSICIANS WELLNESS ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:G
Authorized Official - Last Name:REILLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-410-3800
Mailing Address - Street 1:1920 EAST STATE HIGHWAY 114
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092
Mailing Address - Country:US
Mailing Address - Phone:817-410-3800
Mailing Address - Fax:817-410-6466
Practice Address - Street 1:4735 STATESMEN DRIVE , SUITE C
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250
Practice Address - Country:US
Practice Address - Phone:317-595-5698
Practice Address - Fax:317-585-5086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty