Provider Demographics
NPI:1346426533
Name:KURT A. WIESE, M.D., P.C.
Entity Type:Organization
Organization Name:KURT A. WIESE, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KURT
Authorized Official - Middle Name:
Authorized Official - Last Name:WIESE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-462-7773
Mailing Address - Street 1:401 WALL ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-2521
Mailing Address - Country:US
Mailing Address - Phone:219-462-7773
Mailing Address - Fax:219-531-5988
Practice Address - Street 1:401 WALL ST
Practice Address - Street 2:SUITE B
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2521
Practice Address - Country:US
Practice Address - Phone:219-462-7773
Practice Address - Fax:219-531-5988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-17
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040290207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0000091658OtherANTHEM
IN0000091658OtherANTHEM