Healthcare Provider Details

I. General information

NPI: 1609921931
Provider Name (Legal Business Name): REBECCA ANDRESEN WIESE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 10/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1227 E RUSHOLME ST
DAVENPORT IA
52803-2459
US

IV. Provider business mailing address

5410 MARYLAND WAY SUITE 300
BRENTWOOD TN
37027-5064
US

V. Phone/Fax

Practice location:
  • Phone: 563-421-3121
  • Fax: 563-421-3129
Mailing address:
  • Phone: 615-377-5652
  • Fax: 888-241-1404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number22167
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: