Provider Demographics
NPI:1093713166
Name:WEIZER, ILENE KATZ (MD)
Entity Type:Individual
Prefix:
First Name:ILENE
Middle Name:KATZ
Last Name:WEIZER
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:PO BOX 783311
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-3311
Mailing Address - Country:US
Mailing Address - Phone:484-884-4500
Mailing Address - Fax:484-884-0699
Practice Address - Street 1:700 SCHUYLKILL MANOR RD STE 206
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901
Practice Address - Country:US
Practice Address - Phone:570-628-4200
Practice Address - Fax:570-628-4824
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD047488L207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014618530004Medicaid
PA053815Medicare PIN
PA0014618530004Medicaid