Basic Information
| Provider Information | |||||||||
| NPI: | 1023016623 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEIL | ||||||||
| FirstName: | LOWELL | ||||||||
| MiddleName: | SCOTT | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1455 E GOLF RD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | DES PLAINES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600161250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473907666 | ||||||||
| FaxNumber: | 8473909345 | ||||||||
| Practice Location | |||||||||
| Address1: | 1455 E GOLF RD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | DES PLAINES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600161250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473907666 | ||||||||
| FaxNumber: | 8473909345 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2005 | ||||||||
| LastUpdateDate: | 12/31/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 016002469 | IL | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213ES0000X | 016002469 | IL | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Sports Medicine | 213ES0131X | 016002469 | IL | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery | 213ES0103X | 016002469 | IL | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 60000380 | 01 | IL | BCBS | OTHER | 1710965314 | 05 | IL | MEDICAID | 201255100A | 05 | IN | MEDICAID | 6039870 | 01 | IL | CIGNA | OTHER |