Healthcare Provider Details

I. General information

NPI: 1821191404
Provider Name (Legal Business Name): GARY G WIESMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 04/09/2020
Certification Date: 04/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 N DEARBORN ST
CHICAGO IL
60654-3846
US

IV. Provider business mailing address

712 N DEARBORN ST
CHICAGO IL
60654-3846
US

V. Phone/Fax

Practice location:
  • Phone: 312-796-5550
  • Fax: 312-981-1292
Mailing address:
  • Phone: 312-796-5550
  • Fax: 312-981-1292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number036042623
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: