1639151244 NPI number — JOHN WIEDNER M.D.

Table of content: JOHN WIEDNER M.D. (NPI 1639151244)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639151244 NPI number — JOHN WIEDNER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIEDNER
Provider First Name:
JOHN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639151244
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16759 MAIN ST
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
WILDWOOD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63040-1232
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-458-4800
Provider Business Mailing Address Fax Number:
636-594-7500

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16759 MAIN ST
Provider Second Line Business Practice Location Address:
STE 203
Provider Business Practice Location Address City Name:
WILDWOOD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63040-1232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-458-4800
Provider Business Practice Location Address Fax Number:
636-594-7500
Provider Enumeration Date:
11/18/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  R6G00 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: E10053 . This is a "MERCY" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 113996 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 16748 . This is a "BCBS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 4104267 . This is a "AETNA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 127506 . This is a "GHP" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 0400320 . This is a "UHC" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 000000010043 . This is a "ESSENCE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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