MEDICARE: DR. THOMAS R WIETERS M.D.

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	2086S0129X	Vascular Surgery Physician	10486	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1518149350	OTHER	SC	NPI

General Provider Information

NPI Number	:	1255368106
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS R WIETERS M.D.

Provider Business Mailing Address
First Line	:	3070 N HIGHWAY 17
Second Line	:	SUITE 202
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29466-9300
Country	:	US
Telephone Number	:	843-881-8346
Fax Number	:	843-284-4093

Provider Business Practice Location Address
First Line	:	3070 N HIGHWAY 17
Second Line	:	SUITE 202
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29466-9300
Country	:	US
Telephone Number	:	843-881-8346
Fax Number	:	843-284-4093

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

Provider Enumeration Date	:	06/27/2006
Last Update Date	:	05/24/2026

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