Provider Demographics
NPI:1174510457
Name:PENNY A WESSON MD LLC
Entity Type:Organization
Organization Name:PENNY A WESSON MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WESSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-691-3430
Mailing Address - Street 1:N34W28453 TAYLORS WOODS RD
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-3365
Mailing Address - Country:US
Mailing Address - Phone:262-691-3430
Mailing Address - Fax:
Practice Address - Street 1:N34W28453 TAYLORS WOODS RD
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-3365
Practice Address - Country:US
Practice Address - Phone:262-691-3430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-03
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI46894020207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34571200Medicaid
WI=========OtherEMPLOYER IDENTIFICATION N
WI34571200Medicaid
WI000016008Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER