Healthcare Provider Details

I. General information

NPI: 1811193592
Provider Name (Legal Business Name): LAUREN A. WIEBE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 04/02/2021
Certification Date: 04/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE. PALLIATIVE CARE
EVANSTON IL
60201
US

IV. Provider business mailing address

2650 RIDGE AVE. PALLIATIVE CARE
EVANSTON IL
60201-1718
US

V. Phone/Fax

Practice location:
  • Phone: 847-503-4222
  • Fax: 847-503-4220
Mailing address:
  • Phone: 847-503-4222
  • Fax: 847-503-4220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number036117764
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number036117764
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: