Provider Demographics
NPI:1215180757
Name:GARY WIESMAN MD. LTD
Entity Type:Organization
Organization Name:GARY WIESMAN MD. LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:G
Authorized Official - Last Name:WIESMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-796-5550
Mailing Address - Street 1:712 N DEARBORN ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-3846
Mailing Address - Country:US
Mailing Address - Phone:312-796-5550
Mailing Address - Fax:312-981-1292
Practice Address - Street 1:712 N DEARBORN ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-3846
Practice Address - Country:US
Practice Address - Phone:312-796-5550
Practice Address - Fax:312-981-1292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036042623207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL480320Medicare PIN