Provider Demographics
NPI:1043430747
Name:KARL C WENNER MD PC
Entity Type:Organization
Organization Name:KARL C WENNER MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JEANNETTE
Authorized Official - Middle Name:L
Authorized Official - Last Name:GANSBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-274-2902
Mailing Address - Street 1:2200 BRYANT WILLIAMS DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-1120
Mailing Address - Country:US
Mailing Address - Phone:541-884-7746
Mailing Address - Fax:541-884-0848
Practice Address - Street 1:2200 BRYANT WILLIAMS DR
Practice Address - Street 2:SUITE 1
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-1120
Practice Address - Country:US
Practice Address - Phone:541-884-7746
Practice Address - Fax:541-884-0848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15968174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR098830Medicaid
CAXPY1138303OtherMEDICAL
OR055587000OtherBLUE CROSS
ORDG2429OtherRAIL ROAD MEDICARE
ORAW3278808OtherDEA
OR098830Medicaid
OR=========97601OtherTRICARE
OR098830Medicaid
ORR138986Medicare PIN
ORAW3278808OtherDEA