Provider Demographics
NPI:1891886164
Name:WELLER, STEPHANIE M (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:M
Last Name:WELLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1945 W WILSON AVE STE 4000
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5255
Mailing Address - Country:US
Mailing Address - Phone:773-736-6220
Mailing Address - Fax:773-736-3941
Practice Address - Street 1:1945 W WILSON AVE STE 4000
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5255
Practice Address - Country:US
Practice Address - Phone:773-736-6220
Practice Address - Fax:773-736-3941
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036129096208000000X
MDD64200208000000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036129096Medicaid
MD700LP367Medicare PIN
MD411513900Medicaid
MDP00438591Medicare PIN