Basic Information
| Provider Information | |||||||||
| NPI: | 1073560876 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WESENBERG | ||||||||
| FirstName: | BRENT | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1189 | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973391189 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5234 SW PHILOMATH BLVD | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973331042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417684970 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 11/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD26812 | OR | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 174400000X | MD26812 | OR | N | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 240516 | 05 | OR | MEDICAID | 00389270 | 01 | OR | MEDICARE RAILROAD | OTHER |