Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 036126677 | IL |
Y | 207QS0010X | Family Doctor - Sports Medicine | 036126677 | IL |
NPI | 1255597944 |
---|---|
Provider Name | Stephen James Wielgus |
First Address | Lincolnshire, IL 60069-3839 |
Second Address | Lincolnshire, IL 60069 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/08/2008 |
Last Update Date | 16/02/2021 |