Provider Demographics
NPI:1609969765
Name:WIENER, GREGORY ALAN (MD, FACS)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:ALAN
Last Name:WIENER
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7447 W TALCOTT AVE
Mailing Address - Street 2:STE 451
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-3745
Mailing Address - Country:US
Mailing Address - Phone:773-763-3990
Mailing Address - Fax:773-763-6346
Practice Address - Street 1:7447 W TALCOTT AVE
Practice Address - Street 2:STE 451
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-3745
Practice Address - Country:US
Practice Address - Phone:773-763-3990
Practice Address - Fax:773-763-6346
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1623188OtherBCBS
IL554320Medicare ID - Type Unspecified
ILG52391Medicare UPIN