MEDICARE: EDWARD WIESNETH RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	ND12989	FL

General Provider Information

NPI Number	:	1235996117
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDWARD WIESNETH RD

Provider Business Mailing Address
First Line	:	1201 NW 16TH ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33125-1624
Country	:	US
Telephone Number	:	305-575-7000
Fax Number	:

Provider Business Practice Location Address
First Line	:	5000 S 5TH AVE
Second Line	:
City	:	HINES
State	:	IL
Zip	:	60141-3030
Country	:	US
Telephone Number	:	708-202-8387
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/06/2024
Last Update Date	:	01/24/2026

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