MEDICARE: DR. MARTIN P WEINSTEIN PHD

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	103T00000X	Psychologist		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0001634904	OTHER	IL	BCBS PROVIDER

General Provider Information

NPI Number	:	1487742649
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARTIN P WEINSTEIN PHD

Provider Business Mailing Address
First Line	:	717 W BITTERSWEET PL L2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-2375
Country	:	US
Telephone Number	:	773-935-0245
Fax Number	:

Provider Business Practice Location Address
First Line	:	717 W BITTERSWEET PL L2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-2375
Country	:	US
Telephone Number	:	773-935-0245
Fax Number	:

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

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	07/08/2007

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