Provider Demographics
NPI:1215190525
Name:WIISANEN, MICHAEL TYLER (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:TYLER
Last Name:WIISANEN
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 1:870 N ORLEANS ST
Mailing Address - Street 2:APT 3
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-3029
Mailing Address - Country:US
Mailing Address - Phone:701-610-1999
Mailing Address - Fax:
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:708-216-9169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-07
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125053372207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology