Healthcare Provider Details

I. General information

NPI: 1164395562
Provider Name (Legal Business Name): MARY WIRTH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2025
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 E WOODFIELD RD STE 300
SCHAUMBURG IL
60173-4776
US

IV. Provider business mailing address

3595 WATERSCAPE TER
ELGIN IL
60124-5715
US

V. Phone/Fax

Practice location:
  • Phone: 847-605-9500
  • Fax: 847-605-8700
Mailing address:
  • Phone: 224-465-2631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number209033159
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number209033159
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: