Basic Information
| Provider Information | |||||||||
| NPI: | 1467566398 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIEGAND | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 ELMWOOD AVE | ||||||||
| Address2: | BOX 655 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146428655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852759555 | ||||||||
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| Practice Location | |||||||||
| Address1: | 601 ELMWOOD AVE | ||||||||
| Address2: | BOX 655 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146428655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852759555 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 04/13/2011 | ||||||||
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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 | 207R00000X | A88509 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 017860 | ME | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 017860 | ME | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207PT0002X | 017860 | ME | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Medical Toxicology | 207PT0002X | 258256 | NY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Medical Toxicology |
ID Information
| ID | Type | State | Issuer | Description | 03257283 | 05 | NY | MEDICAID | 432977599 | 05 | ME | MEDICAID | 30207895 | 05 | NH | MEDICAID |