Provider Demographics
NPI:1194897587
Name:WIESMAN, IRVIN MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:IRVIN
Middle Name:MICHAEL
Last Name:WIESMAN
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 1:712 N DEARBORN ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-3818
Mailing Address - Country:US
Mailing Address - Phone:312-981-1290
Mailing Address - Fax:312-981-1292
Practice Address - Street 1:712 N DEARBORN ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-3818
Practice Address - Country:US
Practice Address - Phone:312-981-1290
Practice Address - Fax:312-981-1292
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036095961208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036095961Medicaid
01633365OtherBCBS
H80822Medicare UPIN
IL036095961Medicaid