Provider Demographics
NPI:1306855572
Name:WIEBE, SUSAN H (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:H
Last Name:WIEBE
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:PO BOX 505262
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5262
Mailing Address - Country:US
Mailing Address - Phone:620-688-6566
Mailing Address - Fax:620-688-6577
Practice Address - Street 1:801 W 8TH ST
Practice Address - Street 2:
Practice Address - City:COFFEYVILLE
Practice Address - State:KS
Practice Address - Zip Code:67337-4109
Practice Address - Country:US
Practice Address - Phone:620-688-6566
Practice Address - Fax:620-688-6577
Is Sole Proprietor?:No
Enumeration Date:2006-08-06
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS30484207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS12381073OtherMULTIPLAN
KS104615OtherBCBS
KS200316370AMedicaid
KS8859OtherPHS
KS236567OtherCOVENTRY
KS107906OtherHPK
KS104615OtherBCBS