Healthcare Provider Details

I. General information

NPI: 1922010230
Provider Name (Legal Business Name): STEVAN WEINE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

912 S WOOD ST
CHICAGO IL
60612-4300
US

IV. Provider business mailing address

912 S WOOD ST
CHICAGO IL
60612-4300
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-7206
  • Fax: 312-996-9788
Mailing address:
  • Phone: 312-996-7206
  • Fax: 312-996-9788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: