Healthcare Provider Details

I. General information

NPI: 1265459838
Provider Name (Legal Business Name): GREGORY P WECKENBROCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 09/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 THOMAS MORE PKWY STE 203
EDGEWOOD KY
41017-5102
US

IV. Provider business mailing address

830 THOMAS MORE PKWY STE 203
EDGEWOOD KY
41017-5102
US

V. Phone/Fax

Practice location:
  • Phone: 859-341-5757
  • Fax: 859-331-4757
Mailing address:
  • Phone: 859-341-5757
  • Fax: 859-331-4757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number23567
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: