Provider Demographics
NPI:1265438907
Name:WEISS, NICHOLAS GREGORY (MD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:GREGORY
Last Name:WEISS
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 1:5803 NEAL AVE N
Mailing Address - Street 2:
Mailing Address - City:OAK PARK HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55082-2177
Mailing Address - Country:US
Mailing Address - Phone:651-439-8807
Mailing Address - Fax:651-439-0232
Practice Address - Street 1:5803 NEAL AVE N
Practice Address - Street 2:
Practice Address - City:OAK PARK HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55082-2177
Practice Address - Country:US
Practice Address - Phone:651-439-8807
Practice Address - Fax:651-439-0232
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN41115207XX0005X
WI44466207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G86140Medicare UPIN
G86140Medicare UPIN
WI49128-0018Medicare PIN
MN949317400Medicaid
MN200002035Medicare ID - Type UnspecifiedMN MEDICARE NUM
MN0572890001Medicare NSC
WI56080-0019Medicare PIN