Healthcare Provider Details

I. General information

NPI: 1215515143
Provider Name (Legal Business Name): LORELA BERBERI WEISE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2021
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 N RUTLEDGE ST FL 4
SPRINGFIELD IL
62702-6700
US

IV. Provider business mailing address

PO BOX 19639
SPRINGFIELD IL
62794-9639
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax: 217-545-1622
Mailing address:
  • Phone: 217-545-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number125.078704
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: