Active NPI
Larissa Wietlisbach
- Plastic Surgery Physician
- Chicago, IL
National Provider Identifier
1982352597
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Plastic Surgery Physician
- License
- 125082534
- Practice address
- 5841 S Maryland Ave # Mc6035
Chicago, IL 60637-1443 - Phone
- (773) 702-6302
- NPI assigned
- Mar 13, 2022
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Plastic Surgery Physician | 208200000X | 125082534 | IL | Primary |
Addresses
Primary practice location
5841 S Maryland Ave # Mc6035
Chicago, IL 60637-1443
Mailing address
180 Harvester Dr Ste 110
Burr Ridge, IL 60527-6686
Phone (773) 702-1150
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in IL
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20230913000891 | IL | Order and Referring Only - Plastic and Reconstructive Surgery | 9234593062 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 125082534 | IL | MD | Plastic Surgery Physician |
Interoperability endpoints
- lwietlisbach191965@uihealth.direct-ci.com
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1647129600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1690848000000",
"number": "1982352597",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "180 HARVESTER DR STE 110",
"city": "BURR RIDGE",
"state": "IL",
"postal_code": "605276686",
"telephone_number": "773-702-1150"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "5841 S MARYLAND AVE # MC6035",
"city": "CHICAGO",
"state": "IL",
"postal_code": "606371443",
"telephone_number": "773-702-6302"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WIETLISBACH",
"first_name": "LARISSA",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2022-03-13",
"last_updated": "2023-08-01",
"certification_date": "2023-08-01",
"status": "A"
},
"taxonomies": [
{
"code": "208200000X",
"taxonomy_group": "",
"desc": "Plastic Surgery",
"state": "IL",
"license": "125082534",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Chicago, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 1, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.