Healthcare Provider Details

I. General information

NPI: 1730800673
Provider Name (Legal Business Name): WILLEM WISSELINK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2022
Last Update Date: 09/08/2022
Certification Date: 09/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 W TAYLOR ST STE 3F
CHICAGO IL
60612-4795
US

IV. Provider business mailing address

1801 W TAYLOR ST STE 3F
CHICAGO IL
60612-4795
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-8459
  • Fax: 312-355-3722
Mailing address:
  • Phone: 312-996-8459
  • Fax: 312-355-3722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number036080102
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: