Provider Demographics
NPI:1518992064
Name:WEISBERGER, RONALD ALAN (DO)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:ALAN
Last Name:WEISBERGER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:829 N CENTER AVE
Mailing Address - Street 2:STE 298
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-1683
Mailing Address - Country:US
Mailing Address - Phone:989-731-7708
Mailing Address - Fax:989-731-7929
Practice Address - Street 1:1996 WALDEN DR
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-8241
Practice Address - Country:US
Practice Address - Phone:989-731-4111
Practice Address - Fax:989-705-8511
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101008157208D00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OF96004OtherMEDICARE GROUP NUMBER
MI4540496Medicaid
CC4805OtherMEDICARE RR PROV ID
MI0156910075OtherBCBSM PROVIDER NUMBER
11291805OtherCAQH PROVIDER ID
381303843OtherTAX ID
MI4540496Medicaid
381303843OtherTAX ID