Healthcare Provider Details

I. General information

NPI: 1992700702
Provider Name (Legal Business Name): STEPHEN M. WIENER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 05/28/2020
Certification Date: 05/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 QUEEN CITY AVE
MANCHESTER NH
03101-7121
US

IV. Provider business mailing address

185 QUEEN CITY AVE
MANCHESTER NH
03101-7121
US

V. Phone/Fax

Practice location:
  • Phone: 603-314-6900
  • Fax: 603-314-6909
Mailing address:
  • Phone: 603-314-6900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number216277
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number17094
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: