MEDICARE: BRENT WEINERMAN D.O.

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	208D00000X	General Practice Physician	OS004236L	PA

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	:	1568476257
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENT WEINERMAN D.O.

Provider Business Mailing Address
First Line	:	897 BRIDGE ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19124-1724
Country	:	US
Telephone Number	:	215-288-7222
Fax Number	:	215-288-7917

Provider Business Practice Location Address
First Line	:	897 BRIDGE ST
Second Line	:
City	:	PHILA
State	:	PA
Zip	:	19124-1724
Country	:	US
Telephone Number	:	215-288-7000
Fax Number	:	215-288-7917

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

Provider Enumeration Date	:	07/28/2006
Last Update Date	:	07/08/2007

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Directions to “ BRENT WEINERMAN D.O.” Practice Location

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