Provider Demographics
NPI:1013177864
Name:WENINGER MEDICAL CORP
Entity Type:Organization
Organization Name:WENINGER MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:WENINGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-324-2229
Mailing Address - Street 1:800 LINCOLNWAY STE 301
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-3439
Mailing Address - Country:US
Mailing Address - Phone:219-324-2229
Mailing Address - Fax:219-324-2229
Practice Address - Street 1:8865 W 400 N
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-9222
Practice Address - Country:US
Practice Address - Phone:219-871-0833
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-16
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01020206174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INDO1275OtherRAILROAD PTAN
IN200000360Medicaid
IN200000360Medicaid