Provider Demographics
NPI:1548258288
Name:WANLESS, ROBERT C (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:C
Last Name:WANLESS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4600 MEMORIAL DR
Mailing Address - Street 2:SUITE 320
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5366
Mailing Address - Country:US
Mailing Address - Phone:618-257-2100
Mailing Address - Fax:618-257-2169
Practice Address - Street 1:4600 MEMORIAL DR
Practice Address - Street 2:SUITE 320
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5366
Practice Address - Country:US
Practice Address - Phone:618-257-2100
Practice Address - Fax:618-257-2169
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036 - 052657208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036052657Medicaid
IL036052657Medicaid
A - 12878Medicare UPIN
ILIL3521024Medicare PIN