Basic Information
| Provider Information | |||||||||
| NPI: | 1366936601 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEGMAN | ||||||||
| FirstName: | CLEM | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 N SHADELAND AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462194959 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 750 BROADWAY STE 350 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468021412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604232675 | ||||||||
| FaxNumber: | 2604236621 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2018 | ||||||||
| LastUpdateDate: | 05/17/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 11020177A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | 208D00000X | 01082724A | IN | N | Allopathic & Osteopathic Physicians | General Practice | 208M00000X | 01082724A | IN | N | Allopathic & Osteopathic Physicians | Hospitalist | 207Q00000X | 01082724A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.