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NPI Code Detail

MEDICARE: WESTERN AVENUE SURGICAL ASSOCIATES, LLC

MEDICARE: WESTERN AVENUE SURGICAL ASSOCIATES, LLC
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
1261QA1903XAmbulatory Surgical Clinic/Center

General Provider Information

NPI Number : 1285859595
Entity Type Code : Organization
Provider Name (Legal Business Name) : WESTERN AVENUE SURGICAL ASSOCIATES, LLC
Provider Business Mailing Address
First Line : 712 N DEARBORN ST
Second Line :
City : CHICAGO
State : IL
Zip : 60654-3818
Country : US
Telephone Number : 312-981-1297
Fax Number :
Provider Business Practice Location Address
First Line : 712 N DEARBORN ST
Second Line :
City : CHICAGO
State : IL
Zip : 60654-3818
Country : US
Telephone Number : 312-981-1297
Fax Number :
Authorized Official
Title or Position : CO-OWNER
Name : DR. GARY WIESMAN
Credential : M.D.
Telephone Number : 312-981-1297
Provider Enumeration Date : 04/13/2007
Last Update Date : 05/06/2009

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