Basic Information
| Provider Information | |||||||||
| NPI: | 1679148480 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIEMKEN | ||||||||
| FirstName: | BRADLEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 558 HUNTMERE DR | ||||||||
| Address2: | |||||||||
| City: | BAY VILLAGE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441402540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408295171 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3700 KOLBE RD | ||||||||
| Address2: | |||||||||
| City: | LORAIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440531611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409604000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2021 | ||||||||
| LastUpdateDate: | 05/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | APP-000470719 | OH | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.