Basic Information
| Provider Information | |||||||||
| NPI: | 1962820100 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WESELOH | ||||||||
| FirstName: | COLLEEN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | QUINN | ||||||||
| OtherFirstName: | COLLEEN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6 13TH AVE E | ||||||||
| Address2: | |||||||||
| City: | POLSON | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598605315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4068835680 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1021 BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142121460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7165293020 | ||||||||
| FaxNumber: | 7165293040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2014 | ||||||||
| LastUpdateDate: | 04/29/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 295871 | NY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 036142994 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | MED-PHYS-LIC-82860 | MT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.