Provider Demographics
NPI:1699753780
Name:WIETIES-MALM, BARBARA MAY (MD)
Entity type:Individual
Prefix:DR
First Name:BARBARA
Middle Name:MAY
Last Name:WIETIES-MALM
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 1:3300 127TH ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406-3802
Mailing Address - Country:US
Mailing Address - Phone:708-388-0423
Mailing Address - Fax:708-388-1477
Practice Address - Street 1:12935 GREGORY ST
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-2428
Practice Address - Country:US
Practice Address - Phone:708-597-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360685722085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01615363OtherGROUP PIN
IL036068572Medicaid
IL964290007Medicare PIN
ILD89349Medicare UPIN
IL01615363OtherGROUP PIN
ILIL3278003Medicare PIN
IL300026083Medicare ID - Type UnspecifiedTRAVELERS MEDICARE
ILP03309Medicare ID - Type Unspecified
IN603160Medicare PIN