Healthcare Provider Details

I. General information

NPI: 1689627507
Provider Name (Legal Business Name): KEVIN A. WEIDMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 07/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 N. 35TH STREET
MILWAUKEE WI
53208
US

IV. Provider business mailing address

950 N. 35TH STREET
MILWAUKEE WI
53208
US

V. Phone/Fax

Practice location:
  • Phone: 414-831-7939
  • Fax: 414-831-7954
Mailing address:
  • Phone: 414-831-7939
  • Fax: 414-831-7954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number36166
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number36166
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number36166
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number36166 HAND SURGERY
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: