Provider Demographics
NPI:1649869678
Name:WELLCARE MEDICARE
Entity type:Organization
Organization Name:WELLCARE MEDICARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CUSTOMER SUPPORT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:CORNELIUS
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD, DO
Authorized Official - Phone:601-268-8000
Mailing Address - Street 1:7700 FORSYTH BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63105-1807
Mailing Address - Country:US
Mailing Address - Phone:314-725-4477
Mailing Address - Fax:
Practice Address - Street 1:7700 FORSYTH BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63105-1807
Practice Address - Country:US
Practice Address - Phone:314-725-4477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-14
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes305R00000XManaged Care OrganizationsPreferred Provider OrganizationGroup - Single Specialty
No163WP0000XNursing Service ProvidersRegistered NursePain ManagementGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical Laboratory
No3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO12365433061OtherCORPORATE OFFICE
MS8420042213OtherENVISION HEALTHCARE
MS8420042213OtherUNITED HEALTHCARE