MEDICARE: MR. DANIEL R WIEST RPAC

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	0039611	NY

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	4937930001	OTHER	NY	MEDICARE DME

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	275191	OTHER	WELLCARE NY
3	DW05762L10	OTHER	BLUE CROSS
4	10050348	OTHER	CDPHP
5	000406870004	OTHER	BLUE SHIELD NENY

NPI Number	:	1073593927
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DANIEL R WIEST RPAC

Provider Business Mailing Address
First Line	:	11835 RT 9W
Second Line	:
City	:	WEST COXSACKIE
State	:	NY
Zip	:	12192-3605
Country	:	US
Telephone Number	:	518-731-9000
Fax Number	:	518-731-9119

Provider Business Practice Location Address
First Line	:	11835 RT 9W
Second Line	:
City	:	WEST COXSACKIE
State	:	NY
Zip	:	12192-3605
Country	:	US
Telephone Number	:	518-731-9000
Fax Number	:	518-731-9119

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

Provider Enumeration Date	:	01/18/2006
Last Update Date	:	01/22/2008

2101 E JEFFERSON ST PPQA MEDICARE COMPLIANCE UNT 6 WEST , KAISER PERMANENTE MID ATLANTIC PERMANENTE MEDICAL GROUP
ROCKVILLE, MD
20852-4908

Practice Phone: 301-816-6660
Practice Fax: 301-816-6308

11835 RT 9W
WEST COXSACKIE, NY
12192-3605