MEDICARE: JOHN WIEDNER M.D.

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	R6G00	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	E10053	OTHER	MO	MERCY
2	113996	OTHER	MO	HEALTHLINK
3	16748	OTHER	MO	BCBS
4	4104267	OTHER	MO	AETNA
5	127506	OTHER	MO	GHP
6	0400320	OTHER	MO	UHC
7	000000010043	OTHER	MS	ESSENCE

General Provider Information

NPI Number	:	1639151244
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN WIEDNER M.D.

Provider Business Mailing Address
First Line	:	16759 MAIN ST
Second Line	:	SUITE 203
City	:	WILDWOOD
State	:	MO
Zip	:	63040-1232
Country	:	US
Telephone Number	:	636-458-4800
Fax Number	:	636-594-7500

Provider Business Practice Location Address
First Line	:	16759 MAIN ST
Second Line	:	STE 203
City	:	WILDWOOD
State	:	MO
Zip	:	63040-1232
Country	:	US
Telephone Number	:	636-458-4800
Fax Number	:	636-594-7500

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

Provider Enumeration Date	:	11/18/2005
Last Update Date	:	05/02/2016

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Directions to “ JOHN WIEDNER M.D.” Practice Location

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