Provider Demographics
NPI:1881856888
Name:WIERENGA, ROBERT WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WILLIAM
Last Name:WIERENGA
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 S KALAMAZOO MALL STE 204
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-4869
Practice Address - Country:US
Practice Address - Phone:269-343-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301092580207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI381360584OtherEMPLOYER IDENTIFICATION NUMBER
MI381360584OtherEMPLOYER IDENTIFICATION NUMBER
MIP08090107Medicare UPIN
MIC96159132Medicare UPIN