Provider Demographics
NPI:1063513893
Name:WIECHERT, MARK A (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:WIECHERT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 N HENDERSON ST
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-1320
Mailing Address - Country:US
Mailing Address - Phone:309-343-1000
Mailing Address - Fax:309-344-1054
Practice Address - Street 1:1707 N HENDERSON ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-1320
Practice Address - Country:US
Practice Address - Phone:309-343-1000
Practice Address - Fax:309-344-1054
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
5471051OtherAETNA
4815127OtherBC/BS
11054102OtherCAQH
IL530390Medicare ID - Type Unspecified
E56332Medicare UPIN