Healthcare Provider Details

I. General information

NPI: 1861616732
Provider Name (Legal Business Name): CHAD A WIESENAUER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 10/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 E GRAY ST
LOUISVILLE KY
40202-1900
US

IV. Provider business mailing address

234 E GRAY ST
LOUISVILLE KY
40202-1900
US

V. Phone/Fax

Practice location:
  • Phone: 502-588-0390
  • Fax: 502-584-5437
Mailing address:
  • Phone: 502-588-0390
  • Fax: 502-584-5437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number01053500A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: