MEDICARE: WEIDE CHIROPRACTIC, INC.

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	111N00000X	Chiropractor	1599-012	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295867356
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEIDE CHIROPRACTIC, INC.

Provider Business Mailing Address
First Line	:	7280 S 13TH ST
Second Line	:	SUITE 201
City	:	OAK CREEK
State	:	WI
Zip	:	53154-1831
Country	:	US
Telephone Number	:	414-768-9000
Fax Number	:	414-768-9004

Provider Business Practice Location Address
First Line	:	7280 S 13TH ST
Second Line	:	SUITE 201
City	:	OAK CREEK
State	:	WI
Zip	:	53154-1831
Country	:	US
Telephone Number	:	414-768-9000
Fax Number	:	414-768-9004

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JEFFREY ANSON WEIDE
Credential	:	D.C.
Telephone Number	:	414-768-9000

Provider Enumeration Date	:	03/12/2007
Last Update Date	:	08/22/2020

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