Provider Demographics
NPI:1720188980
Name:WUDEL, RUSSELL E (PA-C)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:E
Last Name:WUDEL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:744 ESSINGTON RD
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-4912
Mailing Address - Country:US
Mailing Address - Phone:815-729-0700
Mailing Address - Fax:815-729-0707
Practice Address - Street 1:744 ESSINGTON RD
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-4912
Practice Address - Country:US
Practice Address - Phone:815-729-0700
Practice Address - Fax:815-729-0700
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001679207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085001679Medicaid
IL085001679Medicaid
IL204531Medicare ID - Type UnspecifiedMEDICARE PROVIDER #