Provider Demographics
NPI:1326164518
Name:WEDEMEYER, PHILLIPS POPE (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIPS
Middle Name:POPE
Last Name:WEDEMEYER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15218-1501
Mailing Address - Country:US
Mailing Address - Phone:412-241-6365
Mailing Address - Fax:
Practice Address - Street 1:441 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15218-1501
Practice Address - Country:US
Practice Address - Phone:412-241-6365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD011585E2080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006574360002Medicaid
PAWE100411Medicare ID - Type UnspecifiedBLUE SHIELD PROVIDER NUM.
PA0006574360002Medicaid