Basic Information
| Provider Information | |||||||||
| NPI: | 1366557290 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIEMAN | ||||||||
| FirstName: | ANN | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 955534 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631955534 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 172 PROFESSIONAL PKWY | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633792823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6364626106 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 11/25/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 000836 | MO | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 304683204 | 05 | MO | MEDICAID | 480028696 | 01 | RR MCR | OTHER | 131734 | 01 | BLUE CROSS | OTHER | 2700007 | 01 | MO | UNITED HEALTHCARE | OTHER | 104984 | 01 | MO | BLUE SHIELD OF MISSOURI | OTHER |