Basic Information
| Provider Information | |||||||||
| NPI: | 1508868886 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WUESTHOFF EMERGENCY PHYSICIANS-MELBOURNE PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 552205 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336550001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004768646 | ||||||||
| FaxNumber: | 9193823210 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 N WICKHAM RD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329358625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004768646 | ||||||||
| FaxNumber: | 9193823210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | NICHOL | ||||||||
| AuthorizedOfficialFirstName: | CURRIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8004768646 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 34457 | 01 | FL | BCBS | OTHER | 265664700 | 05 | FL | MEDICAID |