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NPI Code Detail

MEDICARE: BRETT MARVIN WIESEN

MEDICARE: BRETT MARVIN WIESEN
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
1208800000XUrology PhysicianMD494110PA

General Provider Information

NPI Number : 1538794664
Entity Type Code : Individual
Provider Name (Legal Business Name) : BRETT MARVIN WIESEN
Provider Business Mailing Address
First Line : 3509 N BROAD ST
Second Line :
City : PHILADELPHIA
State : PA
Zip : 19140-4105
Country : US
Telephone Number : 215-707-3911
Fax Number :
Provider Business Practice Location Address
First Line : 333 COTTMAN AVE
Second Line :
City : PHILADELPHIA
State : PA
Zip : 19111-2434
Country : US
Telephone Number : 215-728-6900
Fax Number : 215-214-1734
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/09/2020
Last Update Date : 06/11/2026

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Directions to “ BRETT MARVIN WIESEN ” Practice Location

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