Provider Demographics
NPI:1083672752
Name:WEINER, EDWARD J (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:J
Last Name:WEINER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201-4109
Mailing Address - Country:US
Mailing Address - Phone:413-477-2752
Mailing Address - Fax:413-496-6836
Practice Address - Street 1:116 WEST AVE
Practice Address - Street 2:FAIRVIEW INTERNAL MEDICINE
Practice Address - City:GREAT BARRINGTON
Practice Address - State:MA
Practice Address - Zip Code:01230
Practice Address - Country:US
Practice Address - Phone:413-528-8647
Practice Address - Fax:413-528-8290
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA151432207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3156575Medicaid
MA3156575Medicaid
C23297Medicare UPIN