MEDICARE: DERICK M WENNING 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	207PP0204X	Pediatric Emergency Medicine (Emergency Medicine) Physician	31019	SC
2	207P00000X	Emergency Medicine Physician	2011-00547	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366603235
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DERICK M WENNING MD

Provider Business Mailing Address
First Line	:	300 E MCBEE AVE FL 4
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29601-2842
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	14 RICHLAND MEDICAL PARK DR STE 350
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29203-6896
Country	:	US
Telephone Number	:	803-434-1663
Fax Number	:

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

Provider Enumeration Date	:	06/23/2008
Last Update Date	:	06/01/2026

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