Provider Demographics
NPI:1487870796
Name:CRAIG W. WIESENHUTTER, MD
Entity type:Organization
Organization Name:CRAIG W. WIESENHUTTER, MD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:W
Authorized Official - Last Name:WIESENHUTTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-765-5447
Mailing Address - Street 1:950 W IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2644
Mailing Address - Country:US
Mailing Address - Phone:208-765-5457
Mailing Address - Fax:208-765-6248
Practice Address - Street 1:950 W IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2644
Practice Address - Country:US
Practice Address - Phone:208-765-5457
Practice Address - Fax:208-765-6248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM4720207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002074200Medicaid
IDB63633Medicare UPIN
ID1377319Medicare ID - Type Unspecified