Basic Information
| Provider Information | |||||||||
| NPI: | 1407898380 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEISMER | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 169 MARTIN AVE | ||||||||
| Address2: | |||||||||
| City: | EPHRATA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 175221724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882052569 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2 MERIDIAN BLVD | ||||||||
| Address2: | 2ND FLR | ||||||||
| City: | WYOMISSING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 196103202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103724957 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 10/24/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD013505E | PA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 000914711 | 05 | PA | MEDICAID |