Basic Information
Provider Information | |||||||||
NPI: | 1700961042 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WIEBER PHYSICAL THERAPY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1961 CARDINAL LN | ||||||||
Address2: | SUITE A | ||||||||
City: | FARIBAULT | ||||||||
State: | MN | ||||||||
PostalCode: | 550214353 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5073332986 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1961 CARDINAL LN | ||||||||
Address2: | SUITE A | ||||||||
City: | FARIBAULT | ||||||||
State: | MN | ||||||||
PostalCode: | 550214353 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5073332986 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/26/2006 | ||||||||
LastUpdateDate: | 01/24/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SCHULTE WIEBER | ||||||||
AuthorizedOfficialFirstName: | MICHELLE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 5073332986 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 102310 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   | 225100000X | 5231 | MN | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 734390600 | 05 | MN |   | MEDICAID | 8B800WI | 01 | MN | PROVIDER NUMBER | OTHER |