Provider Demographics
NPI:1558339820
Name:WIECZOREK, BRIAN J (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:WIECZOREK
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 1:551 MAIN ST 3RD FLOOR ATTN NICOLLE
Mailing Address - Street 2:THE INFORMEDX GROUP
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15901
Mailing Address - Country:US
Mailing Address - Phone:814-539-5724
Mailing Address - Fax:814-536-7092
Practice Address - Street 1:1086 FRANKLIN ST
Practice Address - Street 2:CONEMAUGH EMERGENCY PHYSICIANS GROUP
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905
Practice Address - Country:US
Practice Address - Phone:814-534-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD066165L207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001722056Medicaid
G88590Medicare UPIN
PA025093Medicare ID - Type Unspecified