Provider Demographics
NPI:1295797462
Name:WIEDEMAN, BETH THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:BETH
Middle Name:THOMAS
Last Name:WIEDEMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:5112 WEST TAFT ROAD
Mailing Address - Street 2:SUITE L
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088
Mailing Address - Country:US
Mailing Address - Phone:315-452-2500
Mailing Address - Fax:315-452-2510
Practice Address - Street 1:4000 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 104
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-6635
Practice Address - Country:US
Practice Address - Phone:315-663-0059
Practice Address - Fax:315-663-0123
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2023-05-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY211782207Q00000X
NY211782.207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02158978Medicaid
NYP01176445Medicare PIN
NYJ400081370Medicare PIN
NYCC3731Medicare ID - Type Unspecified
NY02158978Medicaid