Provider Demographics
NPI:1053314484
Name:WEISS, LORI J (MD)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:J
Last Name:WEISS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6840 WINDSOR AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3441
Mailing Address - Country:US
Mailing Address - Phone:708-484-0042
Mailing Address - Fax:708-749-5489
Practice Address - Street 1:6840 WINDSOR AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3441
Practice Address - Country:US
Practice Address - Phone:708-484-0042
Practice Address - Fax:708-749-5489
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360742732080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036074273Medicaid
ILL88068Medicare ID - Type Unspecified
IL036074273Medicaid