Healthcare Provider Details

I. General information

NPI: 1447244496
Provider Name (Legal Business Name): MARY R. WYERS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 09/21/2023
Certification Date: 09/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E CHICAGO AVE # 9
CHICAGO IL
60611-2991
US

IV. Provider business mailing address

225 E CHICAGO AVE # 9
CHICAGO IL
60611-2991
US

V. Phone/Fax

Practice location:
  • Phone: 312-227-4500
  • Fax: 312-227-9785
Mailing address:
  • Phone: 312-227-4500
  • Fax: 312-227-9785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036-105455
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number036-105455
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: