Provider Demographics
NPI:1760448682
Name:WEINER, STUART B (DO)
Entity Type:Individual
Prefix:
First Name:STUART
Middle Name:B
Last Name:WEINER
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 1:7280 S STATE RD
Mailing Address - Street 2:
Mailing Address - City:GOODRICH
Mailing Address - State:MI
Mailing Address - Zip Code:48438-9770
Mailing Address - Country:US
Mailing Address - Phone:810-636-5000
Mailing Address - Fax:810-636-5019
Practice Address - Street 1:7280 S STATE RD
Practice Address - Street 2:
Practice Address - City:GOODRICH
Practice Address - State:MI
Practice Address - Zip Code:48438-9770
Practice Address - Country:US
Practice Address - Phone:810-636-5000
Practice Address - Fax:810-636-5019
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009926207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI111829660Medicaid
MI0B56281Medicare ID - Type Unspecified
E26793Medicare UPIN