Healthcare Provider Details

I. General information

NPI: 1053067181
Provider Name (Legal Business Name): ELEANOR RACHAEL WIEDEMAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELLIE WIEDEMAN PA-C

II. Dates (important events)

Enumeration Date: 02/28/2022
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26025 LAHSER RD FL 2
SOUTHFIELD MI
48033-2606
US

IV. Provider business mailing address

26211 CENTRAL PARK BLVD STE 201
SOUTHFIELD MI
48076-4158
US

V. Phone/Fax

Practice location:
  • Phone: 248-663-1900
  • Fax: 844-598-9633
Mailing address:
  • Phone: 833-667-3627
  • Fax: 833-972-5509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601011030TMP22
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: