MEDICARE: DR. EDMOND S WEISBART 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	207R00000X	Internal Medicine Physician	2003028097	MO

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1467455964
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDMOND S WEISBART MD

Provider Business Mailing Address
First Line	:	660 S EUCLID AVE
Second Line	:	C B 8121
City	:	SAINT LOUIS
State	:	MO
Zip	:	63110-1010
Country	:	US
Telephone Number	:	314-362-5060
Fax Number	:	314-362-6959

Provider Business Practice Location Address
First Line	:	4901 FOREST PARK AVE
Second Line	:	WOHL CLINIC STE 241
City	:	SAINT LOUIS
State	:	MO
Zip	:	63108-1402
Country	:	US
Telephone Number	:	314-362-5060
Fax Number	:	314-362-6959

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

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	01/29/2018

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