Provider Demographics
NPI:1811939234
Name:WIECHERT, RONALD J (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:J
Last Name:WIECHERT
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 GREEN RD
Mailing Address - Street 2:
Mailing Address - City:TIPTON
Mailing Address - State:IA
Mailing Address - Zip Code:52772-9254
Mailing Address - Country:US
Mailing Address - Phone:319-530-3744
Mailing Address - Fax:
Practice Address - Street 1:3333 N SEMINARY ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-1251
Practice Address - Country:US
Practice Address - Phone:309-344-9403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036105962207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK25535Medicare ID - Type UnspecifiedIND MEDICARE NUMBER
ILG15252Medicare UPIN