Provider Demographics
NPI:1639739733
Name:WIESEHAN, REBECCA MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:MARIE
Last Name:WIESEHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BECCA
Other - Middle Name:MARIE
Other - Last Name:WIESEHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3009 N BALLAS RD STE 227A
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2308
Mailing Address - Country:US
Mailing Address - Phone:314-996-7800
Mailing Address - Fax:
Practice Address - Street 1:3009 N BALLAS RD STE 227A
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2308
Practice Address - Country:US
Practice Address - Phone:314-996-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-19
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021014145207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine