Provider Demographics
NPI:1265875959
Name:WELLCARE PHYSICIANS GROUP LLC
Entity type:Organization
Organization Name:WELLCARE PHYSICIANS GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BAHNSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-824-7334
Mailing Address - Street 1:6135 TRUST DR
Mailing Address - Street 2:SUITE 114
Mailing Address - City:HOLLAND
Mailing Address - State:OH
Mailing Address - Zip Code:43528-9358
Mailing Address - Country:US
Mailing Address - Phone:419-491-0041
Mailing Address - Fax:419-491-0042
Practice Address - Street 1:6135 TRUST DR
Practice Address - Street 2:SUITE 114
Practice Address - City:HOLLAND
Practice Address - State:OH
Practice Address - Zip Code:43528-9358
Practice Address - Country:US
Practice Address - Phone:419-491-0041
Practice Address - Fax:419-491-0042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-11
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty