Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | 125.071373 | IL |
Y | 111NI0900X | Internist | 125.071373 | IL |
N | 207R00000X | Internist | 125071373 | IL |
N | 111NI0900X | Internist | 125071373 | IL |
NPI | 1003347519 |
---|---|
Provider Name | Dr. Charles Maxwell Weddington |
First Address | Maywood, IL 60153-3328 |
Second Address | Maywood, IL 60153-3328 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/03/2017 |
Last Update Date | 29/12/2017 |