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General NPI Number Information
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NPI Number | 1528161304
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Entity Type | Individual
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Provider Name | SARAH RENEE WIEDERHOLT MD
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Gender | Female
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Dates
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Enumeration Date | 09/06/2006
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Last Update Date | 11/22/2017
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Provider Practice Location Address
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Address Line | 5210 NORTH BELT HIGHWAY
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City | ST JOSEPH
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State | MO
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Zip | 64506-1211
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Country | US
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Telephone | 816-271-4971
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Fax | 816-271-6010
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Provider Business Mailing Address
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Address Line | 5210 NORTH BELT HIGHWAY
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City | ST JOSEPH
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State | MO
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Zip | 64506-1211
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Country | US
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Telephone | 816-271-4971
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Fax | 816-271-6010
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | T2004018057
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 2008003502
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License Number State | MO
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