Provider Demographics
NPI:1528049491
Name:WEISS, GRETCHEN M (MD)
Entity type:Individual
Prefix:DR
First Name:GRETCHEN
Middle Name:M
Last Name:WEISS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 ROCKEFELLER PLZ
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10020-1903
Mailing Address - Country:US
Mailing Address - Phone:212-332-3670
Mailing Address - Fax:
Practice Address - Street 1:181 W MADISON ST
Practice Address - Street 2:SUITE 4550
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-4510
Practice Address - Country:US
Practice Address - Phone:312-641-2586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036115176207R00000X
MA60694207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3061132Medicaid
E46379Medicare UPIN
MA3061132Medicaid