Provider Demographics
NPI:1902841562
Name:WIEDER, BRIAN H (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:H
Last Name:WIEDER
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 1:1800 15TH ST
Mailing Address - Street 2:STE 130
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-4500
Mailing Address - Country:US
Mailing Address - Phone:970-350-5996
Mailing Address - Fax:970-350-5997
Practice Address - Street 1:1800 15TH ST
Practice Address - Street 2:STE 130
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-4500
Practice Address - Country:US
Practice Address - Phone:970-350-5996
Practice Address - Fax:970-350-5997
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7381A207T00000X
CODR-37026207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOAAA1171Medicare PIN
G70649Medicare UPIN