Basic Information
| Provider Information | |||||||||
| NPI: | 1942316229 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEAVER | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 676 N ST CLAIR | ||||||||
| Address2: | SUITE 2300 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129266000 | ||||||||
| FaxNumber: | 3129266344 | ||||||||
| Practice Location | |||||||||
| Address1: | 676 N ST CLAIR | ||||||||
| Address2: | SUITE 2300 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129266000 | ||||||||
| FaxNumber: | 3129266344 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 09/19/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036095689 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036095689 | 05 | IL | MEDICAID | 0005499562 | 01 | AETNA | OTHER | 110187922 | 01 | RR MEDICARE | OTHER | 362664182 | 01 | CIGNA | OTHER | 362664182 | 01 | HUMANA | OTHER | 0001616367 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER | 362664182 | 01 | UNITED HEALTHCARE | OTHER | 04017 | 01 | IL | BLUE CHOICE | OTHER |