Provider Demographics
NPI:1568476257
Name:WEINERMAN, BRENT (DO)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:WEINERMAN
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 1:897 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19124-1724
Mailing Address - Country:US
Mailing Address - Phone:215-288-7222
Mailing Address - Fax:215-288-7917
Practice Address - Street 1:897 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19124-1724
Practice Address - Country:US
Practice Address - Phone:215-288-7000
Practice Address - Fax:215-288-7917
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS004236L208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA7030010Medicaid
PA7030010Medicaid
PAWE152651Medicare ID - Type Unspecified