Provider Demographics
NPI:1750326120
Name:WINIECKE, EDWARD A (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:A
Last Name:WINIECKE
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 1:550 W WESTERN AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49440-1045
Mailing Address - Country:US
Mailing Address - Phone:231-726-4498
Mailing Address - Fax:231-726-4468
Practice Address - Street 1:1500 E SHERMAN BLVD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1849
Practice Address - Country:US
Practice Address - Phone:234-672-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2024-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44568-020207L00000X, 207R00000X, 207PE0004X
MI4301090180207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIH77406Medicare UPIN