Provider Demographics
NPI:1285629063
Name:WEINER, MARTIN J (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:J
Last Name:WEINER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3 S GREENLEAF ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-3377
Mailing Address - Country:US
Mailing Address - Phone:847-244-0222
Mailing Address - Fax:847-244-7122
Practice Address - Street 1:3 S GREENLEAF ST
Practice Address - Street 2:SUITE A
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-3377
Practice Address - Country:US
Practice Address - Phone:847-244-0222
Practice Address - Fax:847-244-7122
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036071609207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036071609Medicaid
IL036071609Medicaid
ILL15983Medicare PIN