Healthcare Provider Details

I. General information

NPI: 1194897587
Provider Name (Legal Business Name): IRVIN MICHAEL WIESMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 06/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 N DEARBORN ST
CHICAGO IL
60654-3818
US

IV. Provider business mailing address

712 N DEARBORN ST
CHICAGO IL
60654-3818
US

V. Phone/Fax

Practice location:
  • Phone: 312-981-1290
  • Fax: 312-981-1292
Mailing address:
  • Phone: 312-981-1290
  • Fax: 312-981-1292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number036095961
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: