Healthcare Provider Details

I. General information

NPI: 1194739672
Provider Name (Legal Business Name): FREDERICK KEYSER WIESE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 12/21/2019
Certification Date: 12/21/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 ROBERTS ROAD
CANAAN NH
03741
US

IV. Provider business mailing address

18 ROBERTS ROAD
CANAAN NH
03741-1079
US

V. Phone/Fax

Practice location:
  • Phone: 603-523-4343
  • Fax: 603-523-4502
Mailing address:
  • Phone: 603-523-4343
  • Fax: 603-523-4502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number6868
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number6868
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: