MEDICARE: DR. GARY G WIESMAN MD

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	01621610	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1821191404
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY G WIESMAN MD

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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2006
Last Update Date	:	04/09/2020

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