MEDICARE: MERVYN J. WEIS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician		IL
2	207RG0100X	Gastroenterology Physician		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01615327	OTHER	IL	BLUE CROSS
2	36040513	OTHER	IL	IL LICENSE NUMBER

General Provider Information

NPI Number	:	1043212954
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MERVYN J. WEIS MD

Provider Business Mailing Address
First Line	:	4640 N MARINE DR
Second Line	:	SUITE 6100C
City	:	CHICAGO
State	:	IL
Zip	:	60640-5719
Country	:	US
Telephone Number	:	773-769-4411
Fax Number	:	773-769-5140

Provider Business Practice Location Address
First Line	:	4640 N MARINE DR
Second Line	:	SUITE 6100C
City	:	CHICAGO
State	:	IL
Zip	:	60640-5719
Country	:	US
Telephone Number	:	773-769-4411
Fax Number	:	773-769-5140

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2005
Last Update Date	:	09/11/2025

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