Provider Demographics
NPI:1306871793
Name:WIESEMANN, RICHARD J (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:WIESEMANN
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 1:450 EXECUTIVE PARK
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4204
Mailing Address - Country:US
Mailing Address - Phone:502-897-3214
Mailing Address - Fax:502-897-7685
Practice Address - Street 1:4001 DUTCHMANS LN
Practice Address - Street 2:RADIOLOGY
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4714
Practice Address - Country:US
Practice Address - Phone:502-893-1183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY174002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64174006Medicaid
KYC74033Medicare UPIN
KY1276427Medicare ID - Type Unspecified
KY00057009Medicare PIN
KY0639815Medicare ID - Type Unspecified
KY0639915Medicare ID - Type Unspecified