Provider Demographics
NPI:1043212954
Name:WEIS, MERVYN J (MD)
Entity Type:Individual
Prefix:
First Name:MERVYN
Middle Name:J
Last Name:WEIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4640 N MARINE DR
Mailing Address - Street 2:SUITE 6100C
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5719
Mailing Address - Country:US
Mailing Address - Phone:773-769-4411
Mailing Address - Fax:773-769-5140
Practice Address - Street 1:4640 N MARINE DR
Practice Address - Street 2:SUITE 6100C
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5719
Practice Address - Country:US
Practice Address - Phone:773-769-4411
Practice Address - Fax:773-769-5140
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01615327OtherBLUE CROSS
IL36040513OtherIL LICENSE NUMBER
IL36040513OtherIL LICENSE NUMBER
ILD12456Medicare UPIN
ILAW3666469OtherDEA LICENSE NUMBER