Provider Demographics
NPI:1720303605
Name:ARCHANA WAGLE M D A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:ARCHANA WAGLE M D A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ARCHANA
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-615-2200
Mailing Address - Street 1:925 SHERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAKE BLUFF
Mailing Address - State:IL
Mailing Address - Zip Code:60044-2203
Mailing Address - Country:US
Mailing Address - Phone:847-615-2200
Mailing Address - Fax:847-615-2858
Practice Address - Street 1:500 JOHN DEERE RD
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6892
Practice Address - Country:US
Practice Address - Phone:309-779-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-02
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036100676207L00000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036100676Medicaid
G09301Medicare UPIN