Basic Information
| Provider Information | |||||||||
| NPI: | 1215469036 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEISS | ||||||||
| FirstName: | JARED | ||||||||
| MiddleName: | BLAKE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 340 E NORTH WATER ST UNIT 2110 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606110812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473099970 | ||||||||
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| Practice Location | |||||||||
| Address1: | 676 N SAINT CLAIR ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126951292 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2017 | ||||||||
| LastUpdateDate: | 06/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0700X | 036.160070 | IL | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2085R0202X | 036.160070 | IL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.