Provider Demographics
NPI:1124080189
Name:WIEDRICH, THOMAS A (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:WIEDRICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:737 N MICHIGAN AVE
Mailing Address - Street 2:STE 700
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-6662
Mailing Address - Country:US
Mailing Address - Phone:312-337-6960
Mailing Address - Fax:312-337-3601
Practice Address - Street 1:737 N MICHIGAN AVE
Practice Address - Street 2:STE 700
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-6662
Practice Address - Country:US
Practice Address - Phone:312-337-6960
Practice Address - Fax:312-337-3601
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36074824207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036074824Medicaid
E88284Medicare UPIN
IL036074824Medicaid
962570Medicare ID - Type Unspecified