MEDICARE: ILSE R. WIECHERS 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	2084P0805X	Geriatric Psychiatry Physician	048554	CT
2	2084P0800X	Psychiatry Physician	048554	CT

General Provider Information

NPI Number	:	1396871711
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ILSE R. WIECHERS MD

Provider Business Mailing Address
First Line	:	300 GEORGE ST
Second Line	:	SUITE 901
City	:	NEW HAVEN
State	:	CT
Zip	:	06511-6624
Country	:	US
Telephone Number	:	203-785-2117
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 GEORGE ST
Second Line	:	SUITE 901
City	:	NEW HAVEN
State	:	CT
Zip	:	06511-6624
Country	:	US
Telephone Number	:	203-785-2117
Fax Number	:

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

Provider Enumeration Date	:	02/27/2007
Last Update Date	:	03/06/2011

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