Provider Demographics
NPI:1174505671
Name:WEIDNER, FAITH ANN (MD)
Entity Type:Individual
Prefix:
First Name:FAITH
Middle Name:ANN
Last Name:WEIDNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 N MAIN ST
Mailing Address - Street 2:VA MEDICAL CENTER
Mailing Address - City:LEEDS
Mailing Address - State:MA
Mailing Address - Zip Code:01053-9764
Mailing Address - Country:US
Mailing Address - Phone:413-584-4040
Mailing Address - Fax:413-582-3054
Practice Address - Street 1:421 N MAIN ST
Practice Address - Street 2:VA MEDICAL CENTER
Practice Address - City:LEEDS
Practice Address - State:MA
Practice Address - Zip Code:01053-9764
Practice Address - Country:US
Practice Address - Phone:413-584-4040
Practice Address - Fax:413-582-3054
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0219872085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1219874Medicaid
CT300002865Medicare ID - Type Unspecified
CT1219874Medicaid