Basic Information
| Provider Information | |||||||||
| NPI: | 1518992064 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEISBERGER | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | ALAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 829 N CENTER AVE | ||||||||
| Address2: | STE 298 | ||||||||
| City: | GAYLORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497351683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897317708 | ||||||||
| FaxNumber: | 9897317929 | ||||||||
| Practice Location | |||||||||
| Address1: | 1996 WALDEN DR | ||||||||
| Address2: | |||||||||
| City: | GAYLORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497358241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897314111 | ||||||||
| FaxNumber: | 9897058511 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 12/31/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 5101008157 | MI | N | Allopathic & Osteopathic Physicians | General Practice | 207P00000X | 5101008157 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | OF96004 | 01 | MEDICARE GROUP NUMBER | OTHER | 4540496 | 05 | MI | MEDICAID | CC4805 | 01 | MEDICARE RR PROV ID | OTHER | 0156910075 | 01 | MI | BCBSM PROVIDER NUMBER | OTHER | 11291805 | 01 | CAQH PROVIDER ID | OTHER | 381303843 | 01 | TAX ID | OTHER |