Provider Demographics
NPI:1588661318
Name:WEISS, REGIS J (MD)
Entity Type:Individual
Prefix:
First Name:REGIS
Middle Name:J
Last Name:WEISS
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:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LAKE ZURICH
Mailing Address - State:IL
Mailing Address - Zip Code:60047-0909
Mailing Address - Country:US
Mailing Address - Phone:847-956-8700
Mailing Address - Fax:
Practice Address - Street 1:660 N WESTMORELAND RD
Practice Address - Street 2:SUITE 306
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1659
Practice Address - Country:US
Practice Address - Phone:847-956-8700
Practice Address - Fax:847-888-9609
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-090146207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036090146Medicaid
IL201065Medicare PIN
IL201066Medicare PIN
ILA46463Medicare UPIN