Provider Demographics
NPI:1639061757
Name:ILLINOIS MOBILE WOUND PC
Entity type:Organization
Organization Name:ILLINOIS MOBILE WOUND PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLELAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-980-2181
Mailing Address - Street 1:28 MEADOW RUE DR
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-3141
Mailing Address - Country:US
Mailing Address - Phone:618-980-3150
Mailing Address - Fax:
Practice Address - Street 1:28 MEADOW RUE DR
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-3141
Practice Address - Country:US
Practice Address - Phone:618-980-3150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-15
Last Update Date:2025-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty