Healthcare Provider Details

I. General information

NPI: 1699753780
Provider Name (Legal Business Name): BARBARA MAY WIETIES-MALM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 06/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12935 GREGORY ST
BLUE ISLAND IL
60406-2428
US

IV. Provider business mailing address

3300 127TH ST 2ND FLOOR
BLUE ISLAND IL
60406-3802
US

V. Phone/Fax

Practice location:
  • Phone: 708-597-2000
  • Fax:
Mailing address:
  • Phone: 708-388-0423
  • Fax: 708-388-1477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036068572
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: