MEDICARE: KENNETH NIEL WIESERT MD

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	2084P0800X	Psychiatry Physician	01026404A	IN

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	:	1538110101
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH NIEL WIESERT MD

Provider Business Mailing Address
First Line	:	4412 RADNOR RD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46226-2150
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5868 E 71ST ST
Second Line	:	#123
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-4002
Country	:	US
Telephone Number	:	317-885-2334
Fax Number	:

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

Provider Enumeration Date	:	05/16/2006
Last Update Date	:	07/13/2007

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