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General NPI Number Information
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NPI Number | 1215190525
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Entity Type | Individual
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Provider Name | MICHAEL WIISANEN M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/07/2008
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Last Update Date | 10/31/2024
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Provider Practice Location Address
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Address Line | 2160 S 1ST AVE
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City | MAYWOOD
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State | IL
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Zip | 60153-3328
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Country | US
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Telephone | 708-216-9169
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Fax |
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Provider Business Mailing Address
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Address Line | 870 N ORLEANS ST APT 3
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City | CHICAGO
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State | IL
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Zip | 60610-3029
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Country | US
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Telephone | 701-610-1999
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | 036122167
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | 125053372
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License Number State | IL
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