Provider Demographics
NPI:1477561512
Name:WIEBE, ERIC MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:MARK
Last Name:WIEBE
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 1:3911 AVENUE B
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-4617
Mailing Address - Country:US
Mailing Address - Phone:308-630-2101
Mailing Address - Fax:
Practice Address - Street 1:3911 AVENUE B
Practice Address - Street 2:SUITE 1100
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4617
Practice Address - Country:US
Practice Address - Phone:308-630-2101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE19880207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
110111372OtherPALMENTO GBA RR MEDICARE
110111372OtherPALMENTO GBA RR MEDICARE
266965Medicare PIN
NEG10549Medicare UPIN