Healthcare Provider Details

I. General information

NPI: 1104405455
Provider Name (Legal Business Name): BENJAMIN RUSSELL WIENER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2021
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 OAKSIDE DR STE 203
CANTON GA
30114-2475
US

IV. Provider business mailing address

1320 OAKSIDE DR STE 203
CANTON GA
30114-2475
US

V. Phone/Fax

Practice location:
  • Phone: 770-479-2322
  • Fax: 770-720-7695
Mailing address:
  • Phone: 770-479-2322
  • Fax: 770-720-7695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number112076
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number112076
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: