Provider Demographics
NPI:1760602254
Name:WENONA HEALTH CENTER S C
Entity Type:Organization
Organization Name:WENONA HEALTH CENTER S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-853-4402
Mailing Address - Street 1:516 S. CHESTNUT ST
Mailing Address - Street 2:PO BOX 250
Mailing Address - City:WENONA
Mailing Address - State:IL
Mailing Address - Zip Code:61377
Mailing Address - Country:US
Mailing Address - Phone:815-853-4402
Mailing Address - Fax:
Practice Address - Street 1:516 S. CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:WENONA
Practice Address - State:IL
Practice Address - Zip Code:61377
Practice Address - Country:US
Practice Address - Phone:815-853-4402
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X, 208000000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0006200024OtherBLUE CROSS BLUE SHIELD ID
IL215342Medicare PIN