MEDICARE: THOMAS RUSSELL WIETERS, M.D., P.A.

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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1518149350
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THOMAS RUSSELL WIETERS, M.D., P.A.

Provider Business Mailing Address
First Line	:	3070 HIGHWAY 17 N
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 HIGHWAY 17 N
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	:	OWNER
Name	:	DR. THOMAS RUSSELL WIETERS
Credential	:	M.D.
Telephone Number	:	843-881-8346

Provider Enumeration Date	:	12/04/2007
Last Update Date	:	03/19/2008

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