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NPI Code Detail

MEDICARE: DR. LEXY WISTENBERG M.D.

MEDICARE: DR. LEXY WISTENBERG M.D.
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
1207R00000XInternal Medicine Physician036082382IL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
101632926OTHERILBLUE CROSS BLUE SHIELD

General Provider Information

NPI Number : 1750389201
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. LEXY WISTENBERG M.D.
Provider Business Mailing Address
First Line : 29373 NETWORK PL
Second Line :
City : CHICAGO
State : IL
Zip : 60673-1293
Country : US
Telephone Number : 847-390-5900
Fax Number : 847-967-5147
Provider Business Practice Location Address
First Line : 6131 DEMPSTER ST
Second Line :
City : MORTON GROVE
State : IL
Zip : 60053-2953
Country : US
Telephone Number : 847-967-5010
Fax Number : 847-967-5147
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/08/2005
Last Update Date : 05/12/2022

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