Healthcare Provider Details

I. General information

NPI: 1295239762
Provider Name (Legal Business Name): RYAN MICHAEL WEISS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2018
Last Update Date: 08/04/2025
Certification Date: 08/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 WILLOW SPRINGS RD STE 260
LA GRANGE HIGHLANDS IL
60525-6537
US

IV. Provider business mailing address

120 W 22ND ST
OAK BROOK IL
60523-1557
US

V. Phone/Fax

Practice location:
  • Phone: 708-354-1306
  • Fax: 708-354-1538
Mailing address:
  • Phone: 630-573-5000
  • Fax: 630-491-5472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number036.155384
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number54096
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036.155384
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number54096
License Number StateKY
# 5
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number036.155384
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: