Provider Demographics
NPI:1093907727
Name:TERRIE L WEIR MEDICAL PC
Entity Type:Organization
Organization Name:TERRIE L WEIR MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:WEIR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-366-7177
Mailing Address - Street 1:7605 1/2 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1133
Mailing Address - Country:US
Mailing Address - Phone:708-366-4888
Mailing Address - Fax:
Practice Address - Street 1:7605 1/2 NORTH AVE
Practice Address - Street 2:
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-1133
Practice Address - Country:US
Practice Address - Phone:708-366-4888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-16
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036081633174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036081633Medicaid
IL01635987OtherBCBS IL
IL212887Medicare Oscar/Certification
ILK24502Medicare PIN