Basic Information
Provider Information | |||||||||
NPI: | 1265545693 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WIEFLING | ||||||||
FirstName: | BRIDGETTE | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1425 PORTLAND AVE | ||||||||
Address2: |   | ||||||||
City: | ROCHESTER | ||||||||
State: | NY | ||||||||
PostalCode: | 146213001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5859224430 | ||||||||
FaxNumber: | 5859221399 | ||||||||
Practice Location | |||||||||
Address1: | 1425 PORTLAND AVE | ||||||||
Address2: |   | ||||||||
City: | ROCHESTER | ||||||||
State: | NY | ||||||||
PostalCode: | 146213001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5859224430 | ||||||||
FaxNumber: | 5859221399 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/17/2006 | ||||||||
LastUpdateDate: | 04/30/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 236522 | NY | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 207R00000X | 236522 | NY | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 172800BJ | 01 | NY | PREFERRED CARE | OTHER | P010236522 | 01 | NY | BLUE CROSS OF ROCHESTER | OTHER | 01130026/RGH | 05 | NY |   | MEDICAID | 03406397/WNY | 05 | NY |   | MEDICAID | 236522 | 05 | NY |   | MEDICAID | 01131126/RGH | 05 | NY |   | MEDICAID | 03007072/OPD | 05 | NY |   | MEDICAID | P010236522 | 01 | NY | BLUE CHOICE OF ROCHESTER | OTHER |