Provider Demographics
NPI:1033176672
Name:WIEBKE, ERIC ALAN (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:ALAN
Last Name:WIEBKE
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 1:545 BARNHILL DRIVE
Mailing Address - Street 2:EH 5TH FLOOR UNIVERSITY SURGEONS, INC
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5125
Mailing Address - Country:US
Mailing Address - Phone:317-274-4990
Mailing Address - Fax:317-274-0241
Practice Address - Street 1:545 BARNHILL DRIVE
Practice Address - Street 2:EH 5TH FLOOR UNIVERSITY SURGEONS, INC
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5125
Practice Address - Country:US
Practice Address - Phone:317-274-3086
Practice Address - Fax:317-274-0241
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1039431A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100354900Medicaid
C48933Medicare UPIN
IN233690AAMedicare ID - Type Unspecified