Provider Demographics
NPI:1942316229
Name:WEAVER, STEPHANIE LYNN (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYNN
Last Name:WEAVER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:676 N ST CLAIR
Mailing Address - Street 2:SUITE 2300
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2922
Mailing Address - Country:US
Mailing Address - Phone:312-926-6000
Mailing Address - Fax:312-926-6344
Practice Address - Street 1:676 N ST CLAIR
Practice Address - Street 2:SUITE 2300
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2922
Practice Address - Country:US
Practice Address - Phone:312-926-6000
Practice Address - Fax:312-926-6344
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036095689207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036095689Medicaid
0005499562OtherAETNA
110187922OtherRR MEDICARE
362664182OtherCIGNA
362664182OtherHUMANA
IL0001616367OtherBLUE CROSS BLUE SHIELD
362664182OtherUNITED HEALTHCARE
IL04017OtherBLUE CHOICE
IL04017OtherBLUE CHOICE