MEDICARE: DR. FRED LEE WEDEKING MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	4301026782	MI

General Provider Information

NPI Number	:	1063847416
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FRED LEE WEDEKING MD

Provider Business Mailing Address
First Line	:	1034 CROWN ST
Second Line	:
City	:	KALAMAZOO
State	:	MI
Zip	:	49006-2102
Country	:	US
Telephone Number	:	269-381-3960
Fax Number	:	269-381-3960

Provider Business Practice Location Address
First Line	:	1034 CROWN ST
Second Line	:
City	:	KALAMAZOO
State	:	MI
Zip	:	49006-2102
Country	:	US
Telephone Number	:	269-381-3960
Fax Number	:	269-381-3960

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/04/2013
Last Update Date	:	12/02/2015

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