Provider Demographics
NPI:1871726067
Name:WILDWOOD INTERNAL MEDICINE, PC
Entity type:Organization
Organization Name:WILDWOOD INTERNAL MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:WIEDNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:636-458-4800
Mailing Address - Street 1:16759 MAIN STREET
Mailing Address - Street 2:SUITE 203
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63040
Mailing Address - Country:US
Mailing Address - Phone:636-458-4800
Mailing Address - Fax:636-594-7500
Practice Address - Street 1:16759 MAIN STREET
Practice Address - Street 2:SUITE 203
Practice Address - City:WILDWOOD
Practice Address - State:MO
Practice Address - Zip Code:63040
Practice Address - Country:US
Practice Address - Phone:636-458-4800
Practice Address - Fax:636-594-7500
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WILDWOOD INTERNAL MEDICINE, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-03
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty