Provider Demographics
NPI:1700915634
Name:WIEDLIN, MARTHA (PT)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:WIEDLIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4920 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-2338
Mailing Address - Country:US
Mailing Address - Phone:773-205-8911
Mailing Address - Fax:773-763-3056
Practice Address - Street 1:4920 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-2338
Practice Address - Country:US
Practice Address - Phone:773-205-8911
Practice Address - Fax:773-763-3056
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK23421Medicare ID - Type Unspecified