Provider Demographics
NPI:1245239870
Name:WIEGAND, ROSEMARY
Entity Type:Individual
Prefix:
First Name:ROSEMARY
Middle Name:
Last Name:WIEGAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 GRAMPIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 GRAMPIAN BLVD
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-1907
Practice Address - Country:US
Practice Address - Phone:570-320-7680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD061296L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAG45867Medicare UPIN
PAP00715725Medicare PIN
PA895440OtherBS
PA0016436310004Medicaid
PA003196OtherFIRST PRIORITY HEALTH
PA22470OtherGHP
PA50009422OtherCAPBC
PA002906OtherFP
PAG45867Medicare UPIN
PA0016436310002Medicaid
PA895440Medicare PIN