MEDICARE: GARY WIESMAN MD. LTD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207YX0905X	Otolaryngology/Facial Plastic Surgery Physician	036042623	IL

General Provider Information

NPI Number	:	1215180757
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GARY WIESMAN MD. LTD

Provider Business Mailing Address
First Line	:	712 N DEARBORN ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60654-3846
Country	:	US
Telephone Number	:	312-796-5550
Fax Number	:	312-981-1292

Provider Business Practice Location Address
First Line	:	712 N DEARBORN ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60654-3846
Country	:	US
Telephone Number	:	312-796-5550
Fax Number	:	312-981-1292

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GARY G WIESMAN
Credential	:	MD
Telephone Number	:	312-796-5550

Provider Enumeration Date	:	10/28/2008
Last Update Date	:	04/10/2020

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