Provider Demographics
NPI:1710102660
Name:EDMUND W VIZINAS, MD SC
Entity Type:Organization
Organization Name:EDMUND W VIZINAS, MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDMUND
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:VIZINAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-229-9965
Mailing Address - Street 1:6918 W ARCHER AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-2337
Mailing Address - Country:US
Mailing Address - Phone:773-229-9965
Mailing Address - Fax:773-229-9849
Practice Address - Street 1:6918 W ARCHER AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-2337
Practice Address - Country:US
Practice Address - Phone:773-229-9965
Practice Address - Fax:773-229-9849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL31600576OtherBCBS
IL229840Medicare PIN